HEALTH ASSESSMENT TTL's Day 1-5

A. Notify the practitioner. The skipping of every third heartbeat signifies an arrhythmia, which may be dangerous and should be reported to the practitioner as soon as possible. Documenting the finding for later review could be detrimental to the patient. Ordering laboratory tests is not within the nurse's scope of practice. Heart massage is an open chest procedure performed only by practitioners in a critical situation.

. The nurse is assessing the apical pulse of a patient who has had a normal heart rhythm during the past several assessments. What should the nurse do when every third heartbeat is now skipped during the entire minute of apical pulse assessment? A. Notify the practitioner. B. Order laboratory testing for cardiac enzyme levels. C. Document the finding for later review. D. Perform heart massage.

D. Virchow triad Three elements (commonly referred to as the Virchow triad) contribute to the development of VTE: hypercoagulability of the blood, venous wall damage, and stasis of blood flow. Signs of infection are best assessed by looking at the white blood cell count and differential, as well as by looking at vital signs and the clinical picture. Increased bleeding tendencies may be recognized in the coagulation studies, but the risk for a patient on bed rest is VTE caused by inactivity and blood stasis. Thrombocytopenia is indicated by a low platelet count and signifies a possible risk for bleeding.

1. A patient is on bed rest following a hip replacement. What is the nurse assessing for when checking the patient's circulation and coagulation studies? A. Increased bleeding tendency B. Signs of infection C. Thrombocytopenia D. Virchow triad

C. High-Fowler position The patient should maintain an upright (high-Fowler) position when practicing controlled coughing to facilitate diaphragm excursion and enhance thorax and abdominal expansion. Supine, side-lying, and Trendelenburg positions are not recommended for controlled coughing because these positions do not facilitate diaphragm excursion and do not enhance thorax and abdominal expansion.

2. The nurse is preparing to teach the patient diaphragmatic breathing. Which position should the nurse assist the patient into? A. Side-lying position B. Supine position C. High-Fowler position D. Trendelenburg position

A. Administer an analgesic. Before implementing deep breathing for the first time, the nurse may administer an analgesic so the patient can gain the level of comfort needed to perform the technique effectively. The nurse should explain that comfort-promotion strategies can be an effective addition to pain control. Patient-controlled analgesia may be used with deep breathing.

4. Which action is appropriate before a nurse implements a comfort promotion strategy, such as deep breathing, for the first time? A. Administer an analgesic. B. Ensure that the patient has not received an analgesic for at least 2 hours. C. Explain to the patient that many times comfort-promotion strategies are ineffective. D. Stop patient-controlled analgesia.

D. Determine that the patient has no neck injury. The nurse must ensure that the patient has no neck injury or condition that contraindicates neck manipulation before beginning a neck massage. The patient should be in the prone position during a neck massage, not the Fowler position. A sedative is not required before a neck massage. A neck message works in conjunction with PCA to decrease the patient's pain and in turn decrease the amount of pain medication the patient requires. Stopping the PCA pump may increase the patient's pain level.

5. What should the nurse do before providing a neck massage to a patient? A. Stop the patient-controlled analgesia pump. B. Have the patient sit up in the Fowler position. C. Administer a sedative to help the patient sleep. D. Determine that the patient has no neck injury.

C. In a supine position A young infant is not able to hold up his or her head to maintain a patent airway because of limited neck strength and a relatively heavy head. For this reason, a young infant should be treated in the supine position or while being held. Both the tripod position and the high Fowler position require head and neck strength beyond a 3-month-old infant's capability. Infants should not be supported by pillows because flexion of the airway and further respiratory compromise may result.

A 3-month-old infant is brought to the emergency department with moderate respiratory distress. The parents are not present. How should this infant be positioned? A. In the orthopnea (tripod) position B. In a high Fowler position C. In a supine position D. Supported by pillows

A. A soft grunt with each expiration Nasal flaring, grunting, or head bobbing in infants is a sign of dyspnea. The AP diameter is normally a 1:1 ratio in children, changing to 2:1 in adulthood. Abdominal breathing is commonly seen in children younger than 7 years of age. Respiratory rates in children are higher than in adults; 30 breaths per minute is an acceptable rate for an infant.

A 4-month-old infant is admitted for respiratory distress. Which finding is indicative of respiratory distress? A. A soft grunt with each expiration B. AP diameter of a 1:1 ratio C. Abdominal breathing D. A respiratory rate of 30 breaths per minute

D. Ensure that side rails are up after providing care. To prevent falls, the nurse must ensure that the side rails remain up whenever a young child is unattended. Beds should be at the lowest position as a safety precaution. Children should be provided with activities that stimulate movement, such as coloring. The child's mother should be encouraged to remain in the room during position changes for support and encouragement.

A 4-year-old child is immobilized after hip surgery. Which intervention should the nurse perform? A. Ask the child's mother to leave the room to avoid upsetting her with position changes. B. Remove the coloring books so the child can rest. C. Leave the bed at waist height because the child requires frequent care. D. Ensure that side rails are up after providing care.

C. Apply a Venturi mask and titrate the oxygen flow to maintain a normal SpO2 Because the patient has COPD and may have chronic hypercapnia, maintaining an SpO2 that is normal for the patient is important. A Venturi mask allows more precise delivery of oxygen concentrations between 24% and 50%. Increasing the oxygen flow rate may result in hypoventilation and possibly hypoxia and apnea. A nasal cannula at 2 L/min may not provide sufficient oxygen for this patient. The patient needs oxygen therapy and should not take off the mask.

A 53-year-old patient with a history of COPD presents to the emergency department in respiratory distress. The prehospital care providers have placed the patient on a 100% nonrebreather mask. When the patient arrives in the emergency department, which action should be taken? A. Increase the oxygen flow rate until the patient's SpO2 is 100%. B. Change the mask to a nasal cannula at 2 L/min to prevent hypercapnia. C. Apply a Venturi mask and titrate the oxygen flow to maintain a normal SpO2 D. Allow the patient to take the mask off when he feels he is getting enough oxygen.

D. Notify the practitioner of the probable fecal impaction Because digital fecal impaction removal is not recommended in children, the nurse should notify the practitioner for further evaluation. A saline enema does not resolve fecal impaction in a child. Digital removal of stool is not recommended in pediatric patients because of the risk of anal fissures and pain, which trigger stool withholding. A dose of milk of magnesia is not sufficient to resolve fecal impaction in a child.

A 6-year-old child with abdominal distention and nausea strains to have a bowel movement. Only a small amount of dark brown fecal liquid is produced, indicating a probable fecal impaction. What should the nurse do? A. Administer 200 ml of saline enema B. Digitally remove the fecal impaction C. Administer milk of magnesia at bedtime D. Notify the practitioner of the probable fecal impaction

B. Combination of sleep and medication The patient's initial slow HR probably results from a combination of sleep and medication; beta blockers may slow the HR. Some medications—antiarrhythmics, sympathomimetics, and cardiotonics—affect the rate and rhythm of the pulse, and general anesthetics and large doses of opioid analgesics slow the HR. Athletic conditioning may cause bradycardia, but because the patient is overweight, this is less likely to be the cause. Caffeine is a cardiac stimulant and may cause tachycardia. Monitor artifact does not mimic a low HR.

A 62-year-old overweight male patient has a history of cardiovascular disease and hypertension, but his history is negative for myocardial infarction. He is taking beta blockers and a diuretic. When the nurse performs a 2:00 AM assessment on the patient, his HR is 44 bpm. Upon awakening, his HR increases to 64 bpm, and his blood pressure is 98/44 mm Hg. What is the most probable reason for the initially low HR? A. Monitor artifact B. Combination of sleep and medication C. Athletic conditioning D. Caffeine intake

A. Homans sign A Homans sign alerts the nurse that the patient has a deep vein thrombus. This sign consists of calf pain on dorsiflexion of the foot. Battle sign is ecchymosis over the mastoid bone, seen in patients with a basilar skull fracture. Both Kernig and Brudzinski signs are used to diagnose meningitis.

A 74-year-old patient who had an exploratory laparotomy 4 days ago reports pain in the lower right leg. The nurse assesses the complaint and determines that calf pain occurs when the patient dorsiflexes the right foot. What is this finding called? A. Homans sign B. Battle sign C. Kernig sign D. Brudzinski sign

C. Notify the practitioner. Notify the practitioner immediately when there is a noted change in pulse strength, especially when signs and symptoms suggest peripheral ischemia. Assessments such as the temperature of the extremity, the presence of lesions or ulcers, and any preexisting medical condition are completed prior to beginning the procedure.

A change has been observed in a patient's pulse strength. What is the most appropriate action to take? A. Assess the temperature of the patient's skin. B. Assess the skin for lesions or ulcers. C. Notify the practitioner. D. Assess the patient for peripheral vascular disease.

C. Flexed 30 degrees at the knee with a pillow at the knees Slight flexion breaks up any abnormal extension pattern of the leg, which is worse in the supine position. Flexion of 90 degrees at the hip is too much and thus is inappropriate. Pillows should be between the knees and, if necessary to reduce pressure injuries, the ankles.

A hemiplegic patient with spasticity is in the prone position with a pillow under the hip on the affected side. What is the optimal position for this patient's affected leg? A. Flexed 90 degrees from the hip with a pillow at the pelvis B. Flexed 90 degrees at the knee with a pillow at the ankles C. Flexed 30 degrees at the knee with a pillow at the knees D. Flexed 30 degrees from the hip with a pillow at the back

D. Gently return the foreskin to its natural position. After cleansing the penis, the nurse should return the foreskin to its natural position. The foreskin should never be forced or pushed back beyond the tip of the penis. At this point, returning the foreskin to its original position is the priority. Ice is not indicated and would be uncomfortable.

A male patient is complaining of penile pain after his bath. The nurse assesses the patient's uncircumcised penis and notes localized edema at the end of the penile shaft. What should the nurse do next? A. Force the foreskin back to its natural position. B. Gently push the foreskin farther back from the end of the penis. C. Apply an ice pack to the penis to decrease the edema. D. Gently return the foreskin to its natural position.

D. The nurse rolls the patient onto his or her side. Rolling the patient to his or her side requires the least effort from the patient and allows the drawsheet to be fully placed under him or her. Asking the patient to sit up or raise his or her hips does not allow the drawsheet to be placed appropriately and requires extra effort by the patient. If the nurse attempts to lift the patient using the current drawsheet, it cannot be placed fully under the patient.

A new nurse is attempting to place a drawsheet under a patient. The preceptor recognizes that the nurse understands how to place the sheet appropriately when the nurse takes which action? A. The nurse asks the patient to sit up. B. The nurse asks the patient to raise his or her hips. C. The nurse attempts to lift the patient using the current drawsheet. D. The nurse rolls the patient onto his or her side.

C. Faces the direction in which the patient is to be moved The nurse should face the direction of movement. Facing the side of the bed requires twisting the back while moving the patient. Flattening the bed provides easier access to the patient and allows the nurse to reposition the patient to most positions without working against gravity. The nurse's feet should be placed apart with the foot nearer the head of the bed in front of the other foot. A wide base of support improves balance and enables the mover to shift body weight while moving the patient up in bed, thereby reducing the force needed.

A new nurse is helping move a patient up in bed. The performance evaluation reflects that nurse injury prevention technique is followed when the new nurse performs which action? A. Faces the side of the bed B. Raises the bed to a more comfortable position C. Faces the direction in which the patient is to be moved D. Places his or her feet close together

D. Fine, short, interrupted crackling sounds at the end of inspiration or expiration Crackles, also called rales, are fine, short, interrupted crackling sounds heard during the end of inspiration or expiration and are usually not cleared with coughing. Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration that may be cleared by coughing. Wheezes are high-pitched, continuous musical sounds like a squeak heard during inspiration or expiration, are usually louder on expiration, and do not clear with coughing. A pleural friction rub has a dry, grating quality heard best during inspiration, does not clear with coughing, and is heard loudest over the lower lateral anterior surface.

A nurse documents fine crackles heard when auscultating patient's breath sounds. What sounds did the nurse hear? A. Loud, low-pitched, coarse sounds on inspiration B. Dry, grating sounds on inspiration C. High-pitched, musical squeaks on expiration D. Fine, short, interrupted crackling sounds at the end of inspiration or expiration

A. Head turned to the unaffected side The hemiplegic patient's head should be turned toward the affected side to promote the development of neck and trunk extension. Having the affected arm out to the side counteracts external rotation of the shoulder and helps maintain joint mobility. Having the knees flexed with a pillow under the tibial area allows the feet to be off the mattress and at the proper angel. Having the unaffected arm alongside the torso allows a neutral position of the arm and shoulder.

A nurse enters the room of a hemiplegic patient in the prone position. Which finding would require the nurse to reposition the patient? A. Head turned to the unaffected side B. Affected arm out to the side with the elbow bent C. Knees flexed slightly with a pillow under the tibial area D. Knees flexed slightly with a pillow under the tibial area

C. Substitute the incentive spirometer with bubbles or balloons. Bubbles or balloons can be substituted for the incentive spirometer with children who are younger than 4 years old and with those who cannot effectively perform IS. The responsibility for teaching the child how to perform IS exercises should not be placed on the family, and it could be a waste of time to have the family teach if the child is under 4 years old or does not understand the instructions. The nurse should let the practitioner know that other methods are being used for lung expansion.

A nurse is caring for a 3-year-old child who recently had abdominal surgery. The child does not understand how to use the incentive spirometer. What should the nurse do? A. Explain the IS exercise to the family so they can teach the child. B. Notify the practitioner that IS exercises could not be performed with the child C. Substitute the incentive spirometer with bubbles or balloons. D. Continue to try to teach the child throughout the shift.

C. The pregnant patient on bed rest Patients who are immobile, obese, or pregnant would be at risk for blood stasis to the lower extremities. Antiembolic stockings and SCDs would be used to prevent VTE. Patients who are taking oral contraceptives, especially those who smoke, are considered at risk. Contraindications for the use of antiembolic stockings or SCDs include recent skin grafts.

A nurse is caring for four patients. Which patient would be the most likely candidate for the use of antiembolic stockings? A. The patient who smokes B. The patient who is ambulatory C. The pregnant patient on bed rest D. The patient with a skin graft to the lower left extremity

C. Keeping his or her knees and hips locked While moving a patient in bed, the nurse's knees and hips should be flexed. The nurse should face the head of the bed, position his or her foot near the head of the bed in front of the other foot, flex his or her knees and hips, and then shift the weight from the front leg to the back leg to lift the patient.

A nurse is helping move a patient up in the bed. Which position should the nurse avoid? A. Facing the head of the bed B. Placing his or her foot near the head of the bed in front of the other foot C. Keeping his or her knees and hips locked D. Shifting his or her weight from the front leg to the back leg to lift the patient

B. "The joints, tendons, ligaments, and muscles" The term body alignment refers to the condition of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures. When the joints, tendons, ligaments, and muscles are aligned, the head, neck, spine, shoulders, buttocks, legs, and feet are aligned as a result.

A nurse is teaching a new nurse about proper body alignment. The nurse asks the new nurse which parts of the patient's body should be aligned. Which response indicates that the new nurse understands the information? A. "The head, neck, and shoulders" B. "The joints, tendons, ligaments, and muscles" C. "The head, buttocks, and legs" D. "The joints, spine, cartilage, and feet"

A. Standing next to the bed near the patient's upper body, positioning one arm under the patient's head and the opposite shoulder, positioning the other arm under the patient's closer shoulder and arm, and asking an assistant to assume the proper position at the patient's lower torso If the patient can assist, one nurse should be positioned at the patient's upper body, with the arm nearer the head of the bed under the patient's head and opposite shoulder and the other arm under the patient's closer arm and shoulder. An assistant should be positioned at the patient's lower torso. Having another nurse at the patient's feet does not provide shoulder and hip joint support nor does it offer an even distribution of the patient's weight. The patient should be moved up in bed with least two assistants to avoid injury to the nurse. Having the nurse push up on the patient's leg is not proper technique and may cause harm to the nurse or the patient.

A nurse observes that an obese patient has slipped down in bed. Which statement describes how the nurse should move the patient up in bed if the patient can assist? A. Standing next to the bed near the patient's upper body, positioning one arm under the patient's head and the opposite shoulder, positioning the other arm under the patient's closer shoulder and arm, and asking an assistant to assume the proper position at the patient's lower torso B. Standing next to the bed near the patient's upper body, positioning one arm under the patient's head and shoulder, positioning the other arm under the patient's torso, and asking another nurse to assume the proper position at the patient's feet C. Pulling the patient up in bed with the hands placed under the patient's shoulders D. Having the patient pull himself or herself up using the bed rails while the nurse pushes up on the patient's legs

A. Perform only portions of the cardiovascular examination that are absolutely necessary The patient has atypical signs of chest pain. A patient who presents with signs or symptoms of heart problems, such as chest pain, may be suffering a life-threatening condition requiring immediate attention. The nurse should act quickly and perform the portions of the examination that are absolutely necessary. Later, when a patient's condition is stable, a more thorough assessment can reveal baseline heart function and risks for heart disease. Although these symptoms may suggest a gastrointestinal illness, they are also atypical signs of chest pain, a life-threatening condition that takes priority over gastrointestinal illness.

A patient arrives in the emergency department reporting nausea, flulike symptoms, indigestion, back pain, and exhaustion. Initially, the nurse should perform which action? A. Perform only portions of the cardiovascular examination that are absolutely necessary B. Perform a thorough cardiovascular assessment of the patient, including risk factors, family history, and smoking behaviors C. Perform a thorough gastrointestinal assessment of the patient D. Perform only portions of the gastrointestinal examination that are absolutely necessary

A. Intensity and pitch Characteristics of murmurs, such as intensity and pitch, help identify contributing factors. Intensity of a murmur is related to blood flow through the heart or the amount of blood regurgitated. Pitch depends on the velocity of blood flow through the valves. Location and depth are not characteristics that are helpful in identifying contributing factors.

A patient complaining of palpitations is admitted to the unit. The nurse auscultates the patient's heart sounds and notes a murmur. The nurse should assess which characteristics of the murmur? A. Intensity and pitch B. Location and depth C. Pitch and depth D. Location and pitch

D. The extent of the pathologic condition and lobe involvement The areas for drainage are selected based on knowledge of the patient's condition and disease process, physical assessment of the chest, chest x-ray examination results, and extent of the pathologic condition and lobe involvement revealed by the physical examination and chest x-ray findings. Although the patient's history is important, it does not aid in determining where the secretions are located and therefore should not be used to determine the type of CPT that will best improve the patient's pneumonia. Empyema is a contraindication to CPT. Knowledge of the patient's medication does not help determine lung status.

A patient has been admitted with pneumonia and needs CPT. The areas needing drainage can be determined by knowledge of which information? A. The patient's history B. Presence of empyema C. The patient's medications D. The extent of the pathologic condition and lobe involvement

B. Inspect, auscultate, palpate The nurse should always inspect the abdomen first for pulsations, lifts, and heaves; then auscultate all four quadrants for bowel sounds; and finally palpate the abdomen. The abdomen is auscultated before palpating to avoid stimulating peristalsis.

A patient has presented with abdominal pain and fever. The nurse is assessing the abdomen for any abnormalities. What sequence should the nurse use when assessing the abdomen? A. Inspect, palpate, auscultate B. Inspect, auscultate, palpate C. Auscultate, inspect, palpate D. Auscultate, palpate, inspect

A. Direct a fan into the patient's face. The sensation of breathlessness may be reduced by directing a fan to blow across the patient's face. Placing the patient in a supine position may increase the dyspnea. Oral suction equipment should be available but is not an intervention aimed at reducing breathlessness. Increasing the oxygen flow rate does not decrease the sense of breathlessness and is indicated only for hypoxia as evidenced by low oxygen saturation.

A patient is sitting in a position of comfort for the treatment of dyspnea. Which intervention may reduce the feeling of breathlessness? A. Direct a fan into the patient's face. B. Place the patient supine for a backrub. C. Offer oral suctioning. D. Increase the oxygen flow rate.

A. It is contraindicated because the patient has the potential for head and spinal cord injuries. In patients with suspected head or spinal cord injuries, elevating the lower extremities could cause additional injury and should be avoided. The Trendelenburg position also increases intracranial pressure, which may decrease cerebral perfusion pressure and be detrimental to a patient with a head injury. The Trendelenburg position has been shown to worsen rather than improve cardiovascular status by increasing peripheral vascular resistance and decreasing cardiac output.

A patient involved in a motor vehicle collision arrives in the emergency department hypotensive, unresponsive, and tachycardic. In this case, which statement accurately characterizes the Trendelenburg position? A. It is contraindicated because the patient has the potential for head and spinal cord injuries. B. It will improve the patient's cardiovascular status. C. It will increase the patient's blood pressure, thereby improving cerebral perfusion pressure and preventing secondary brain injury. D. It is indicated because of the hypotension; the potential for a spinal cord injury contraindicates the modified Trendelenburg position.

A. It is not a reliable for assessment for VTE. Homans' sign is not a specific or sensitive indicator for VTE and is present in less than one-third of patients with confirmed VTE. The fact that the Homans' test can be painful is not the reason for not pursuing the test. The presence or absence of edema does not exclude the diagnosis of VTE. Manipulation of the legs can result in clots traveling to the lungs but not the brain, so a stroke would be unlikely.

A patient is admitted with a diagnosis of possible VTE. The nurse assesses the patient and finds that the leg is slightly warm, with minimal edema. Why shouldn't the nurse pursue testing for Homans' sign? A. It is not a reliable for assessment for VTE. B. It is extremely painful. C. With minimal edema, VTE is excluded. D. Manipulation of the leg could lead to stroke.

B. Buttocks A roll under the buttocks is not appropriate and may put the pelvis in an unnatural alignment. Supporting the calves keeps the heels from contacting the bed. A pillow under the head maintains proper neck alignment, and support under the arms reduces internal rotation of the shoulders.

A patient is being positioned in the supported Fowler position by family members. The nurse needs to intervene if the family place supports under which area of the body? A. Head B. Buttocks C. Calves D. Forearms

A. Cardiovascular system As part of the cardiovascular assessment, the nurse assesses the dorsalis pedis pulse by placing the first finger on top of the malleolus and rotating the second and third fingers behind the malleolus into the space. Palpating pulses is not included in the assessment of the gastrointestinal, neurologic, and integumentary systems.

A patient is complaining of cold feet. The nurse assesses the distal pulses to evaluate whether the patient's circulation is adequate. Which system is the nurse assessing when palpating the space behind the malleolus? A. Cardiovascular system B. Gastrointestinal system C. Neurologic system D. Integumentary system

C. 2+ edema An imprint that remains visible on the foot for 15 seconds is defined as 2+ edema. 1+ edema disappears rapidly. 3+ edema may last more than 1 minute, and 4+ edema lasts 2 to 5 minutes.

A patient is complaining of swelling in both feet. The nurse palpates the feet, and the imprint of the nurse's finger remains visible on the foot for 15 seconds. What grade of edema would the nurse document? A. 3+ edema B. 1+ edema C. 2+ edema D. 4+ edema

D. Tighten muscles during inhalation and relax muscles during exhalation. Having the patient tighten muscles during inhalation and relax them during exhalation decreases muscle tension and helps diminish arousal of the sympathetic nervous system. Because relaxing muscles during inhalation and tightening muscles during exhalation go against the body's natural breathing technique, they could increase the patient's pain and decrease the chance of relaxation. Instructing the patient to take short breaths as well as asking the patient to hold his or her breath for 30 seconds every other minute may produce dizziness or shortness of breath that can decrease the chance of relaxation.

A patient is experiencing incomplete pain relief from pain medication, and the nurse suggests trying progressive relaxation to promote comfort. Which instruction should the nurse provide? A. Hold the breath for 30 seconds every other minute. B. Relax muscles during inhalation and tighten muscles during exhalation. C. Take short, rapid breaths. D. Tighten muscles during inhalation and relax muscles during exhalation. Rationale: Having the patient tighten muscles during inhalation and relax them during exhalation decreases muscle tension and helps diminish arousal of the sympathetic nervous system. Because relaxing muscles during inhalation and tightening muscles during exhalation go against the body's natural breathing technique, they could increase the patient's pain and decrease the chance of relaxation. Instructing the patient to take short breaths as well as asking the patient to hold his or her breath for 30 seconds every other minute may produce dizziness or shortness of breath that can decrease the chance of relaxation.

C. Improved breath sounds after incentive spirometer use Improved breath sounds are an expected outcome for a patient who uses IS postoperatively. Achieving a target volume of less than 50% is not acceptable. Although some patients with severe COPD may experience some shortness of breath after using an incentive spirometer, shortness of breath should not be an expected outcome for a patient with no respiratory disease. The patient should not develop a fever as a result of using the incentive spirometer.

A patient is recovering from abdominal surgery. The practitioner has ordered the patient to use an incentive spirometer along with directed coughing and deep breathing to decrease the chance of pneumonia. Which outcome related to IS should the nurse expect for this patient? A. Shortness of breath after using the incentive spirometer B. A mild fever C. Improved breath sounds after incentive spirometer use D. Achievement of 25% of baseline

D. Antiembolic stockings may be removed for a short period of time. The antiembolic stockings may be removed for a short period to perform an assessment and for hygiene measures but should be replaced as soon as possible. Soaking stockings is not recommended. Removing antiembolic stockings for long periods places the patient at risk for embolism. Rolling stockings partially down has a constricting effect and can impede venous return.

A patient rolls down the antiembolic stockings to cool down because the stockings make the legs hot and sweaty. What should the nurse tell the patient? A. Antiembolic stockings can be soaked in water before application to keep the legs cool. B. If uncomfortable, the patient should just take the stockings off. C. It is okay to keep the stockings rolled if the patient is more comfortable. D. Antiembolic stockings may be removed for a short period of time.

B. Prepare to initiate intravenous fluids If hypotension persists after a patient has been placed in modified Trendelenburg position, the nurse should prepare to administer IV fluids to increase intravascular volume. Full Trendelenburg position should not be used, as it may cause harm. Chest compressions should not be initiated unless the heart has stopped. A full medical history is important, but the priority must be to stabilize the patient'scondition.

A patient who collapsed while walking into the ED had a blood pressure of 82/50. The patient was placed in modified Trendelenburg position, and now has a blood pressure of 76/45. What should be the nurse's next action? A. Place the patient in full Trendelenburg position B. Prepare to initiate intravenous fluids C. Begin chest compressions D. Obtain a full medical history

C. "You should do 10 repetitions every hour." The nurse should tell the patient to perform 10 repetitions of foot circles every hour as tolerated. The patient should be instructed to practice the exercises consistently throughout the day while awake. The exercises should be started immediately after surgery as soon is the patient is able. The nurse should instruct the patient to coordinate turning and leg exercises with diaphragmatic breathing and coughing exercises in the following sequence: leg exercises, turning, deep breathing, and coughing.

A patient who had surgery yesterday states, "I don't remember how often I am supposed to do foot circles. Can you tell me again?" Which statement is an appropriate response by the nurse? A. "You have to do four sets of four repetitions every 4 hours." B. "You don't have to do the foot circles until postop day 3." C. "You should do 10 repetitions every hour." D. "You should do them immediately after you finish your deep-breathing exercises."

C. May not be a candidate for antiembolic stockings or SCDs The patient is not a candidate for antiembolic stockings or SCD. Contraindications for antiembolic stockings or SCDs include dermatitis or an open skin lesion (such as an ulcer). Homans' sign is not a reliable evaluation tool for VTE. In this case, because of the presence of leg ulcers, the patient is not a candidate for either an SCD or antiembolic stockings.

A patient who has diabetes and is in a coma needs to be turned every 2 hours. During admission, the nurse notices that the patient's legs are cyanotic and cool with two dime-size ulcers on each calf. What does the nurse recognize about this patient? A. May have a VTE and needs to be evaluated by assessing for Homans' sign B. Benefits more from SCDs than from antiembolic stockings C. May not be a candidate for antiembolic stockings or SCDs D. Is at risk for venous stasis and needs antiembolic stockings

A. Tilt the backboard to the left. The weight of the fetus can compress the vena cava and cause supine hypotension in pregnant patients. Tilting the patient to the left will displace this weight off the vena cava and improve venous return to the heart, resulting in improved cardiac output. Tilting the patient to the right will increase the pressure on the vena cava and make the situation worse. The patient may be removed from the backboard if spinal precautions are maintained, but that will not improve her systemic perfusion. Lowering the head of the stretcher will increase the pressure against her diaphragm and may lead to respiratory compromise and decreased cardiac output.

A patient who is 32 weeks pregnant arrives immobilized on a backboard after her car was rear-ended at a stoplight by a vehicle at low speed. She is complaining of dizziness. What should the nurse do immediately? A. Tilt the backboard to the left. B. Tilt the backboard to the right. C. Remove the patient from the backboard. D. Lower the head of the stretcher.

A. Cover the abrasion. If a patient has a skin abrasion that may contaminate the cuff, an impermeable dressing should be placed over the abrasion. Moving the cuff is not appropriate because doing so would alter the results. The practitioner does not need to be notified. The ABI test would not be performed if the patient had an ulcer but can be performed on a patient with an abrasion.

A patient who needs an ABI calculated has a 2-cm × 3-cm (¾-in × 1⅛-in) abrasion above the left ankle. Which step should be taken next? A. Cover the abrasion. B. Move the cuff. C. Notify the practitioner. D. Discontinue the ABI test.

C. Place the probe at a 45-degree angle along the length of the vessel. The probe should be placed over the artery and tilted to a 45-degree angle along the length of the vessel to optimize frequency shifts and signal amplitude. There are no recommended pounds of pressure to be applied to the probe. Excess pressure on the probe may prevent blood from flowing through the artery and give a false result. Transmission gel, not alcohol, is used to facilitate sound transmission. Alcohol should not be used on the probe. Because a blood pressure cuff cannot be inflated above the femoral pulse, this site is not used in the measurement of blood pressure when using a Doppler ultrasound.

A patient who was rescued from a pond is hypothermic and has been intubated. The patient's blood pressure cannot be auscultated. Which technique using the probe is the best for measuring the patient's blood pressure by Doppler ultrasound? A. Apply 2 to 10 lb of pressure to the probe, depending on the depth of the vessel. B. Use alcohol to moisten the area where the probe will be placed. C. Place the probe at a 45-degree angle along the length of the vessel. D. Place the probe directly over the femoral pulse.

C. "I should find a comfortable position and stay there." Discomfort can be a symptom of tissue injury or decreased mobility, and a single position should not be maintained. Changing position and knowing to notify the practitioner of worsening symptoms or potential skin breakdown are appropriate.

A patient with a decreased range of motion and weakness in the upper and lower extremities is scheduled for discharge from the hospital. The nurse should recognize the need for further teaching if the patient makes which statement? A. "I should call my doctor if I see red areas on my elbow." B. "I should change my position at least every two hours." C. "I should find a comfortable position and stay there." D. "I should call my doctor if moving my arms becomes more difficult."

C. "Discomfort is expected, and I should find a comfortable position and remain in it." Discomfort can be a symptom of tissue injury or decreased mobility, and a single position should not be maintained. The patient's statements on changing position, notifying the practitioner about worsening symptoms, and recognizing signs of skin injury are appropriate.

A patient with a decreased range of motion and weakness in the upper and lower extremities is scheduled for discharge from the hospital. The nurse should recognize the need for further teaching if the patient makes which statement? A. "Redness on my elbows is a sign of skin injury." B. "I should change my position at least every 2 hours." C. "Discomfort is expected, and I should find a comfortable position and remain in it." D. "I should call the practitioner if moving my arms becomes more difficult." Rationale: Discomfort can be a symptom of tissue injury or decreased mobility, and a single position should not be maintained. The patient's statements on changing position, notifying the practitioner about worsening symptoms, and recognizing signs of skin injury are appropriate.

B. Applying a high-flow oxygen cannula system If a patient has high-flow oxygen requirements and is not tolerating a mask, a high-flow oxygen cannula system with warming and humidification may be used. A regular nasal cannula cannot effectively deliver oxygen at a flow rate of 10 L/min. This patient requires only high-flow oxygen; placing an endotracheal tube or a tracheostomy tube is not necessary.

A patient with a high oxygen requirement is not tolerating a mask. Which intervention is the most appropriate for this patient? A. Placing an endotracheal tube with mechanical ventilation B. Applying a high-flow oxygen cannula system C. Preparing for a tracheostomy D. Applying a regular nasal cannula with the oxygen flow set at 10 L/min

A. Remove the fecal impaction as ordered, monitoring the patient's pulse before, during, and after the procedure. Patients with a history of arrhythmias or heart disease have a greater risk of changes in heart rhythm resulting from stimulation of the vagus nerve during fecal impaction removal; therefore, the nurse should monitor the patient's pulse before, during, and after removal of a fecal impaction. When a fecal impaction occurs, the only option is digital removal of the stool; neither a rectal sodium phosphate enema nor a soapsuds enema is effective. Because the nurse has already detected the fecal impaction, the next step is to remove it.

A patient with a recent history of a myocardial infarction reports a feeling of abdominal fullness and nausea. The nurse finds that the patient has not had a bowel movement for 6 days and has an impaction. How should the nurse respond? A. Remove the fecal impaction as ordered, monitoring the patient's pulse before, during, and after the procedure. B. Administer a rectal sodium phosphate enema twice a day. C. Initiate an assessment followed by the removal of the fecal impaction. D. Administer a soapsuds enema until the fecal impaction is cleared.

B. Respiratory distress The high Fowler position helps facilitate breathing in patients with respiratory distress. The high Fowler position may cause further complications in a patient who is unresponsive or hemodynamically unstable or a patient who has an obstructed airway.

A patient with dyspnea and which condition should be placed in high Fowler position? A. Obstructed airway B. Respiratory distress C. Hemodynamic instability D. Unresponsiveness

A. Edema of the lower extremities The knee gatch on the stretcher is raised to prevent the patient from sliding down toward the foot of the stretcher. However, knee gatch should be used for only a limited time because of pressure created on the popliteal vessels. If the patient has been sitting for an extended period, the health care team member should assess the lower extremities for complications. Assessing the patient for pain, tachycardia, and decreased urine output may be indicated by other conditions but specific to the use of the knee gatch, assessment of the lower extremities is the priority.

A patient with dyspnea has been sitting on a stretcher in the emergency department for several hours waiting to be transferred to a medical unit. The gatch on the stretcher has been raised to support the high Fowler position. The health care team member should assess the patient for which condition? A. Edema of the lower extremities B. Pain C. Increased heart rate D. Decreased urine output

B. Right upper quadrant The liver is located in the right upper quadrant of the abdomen. The spleen and stomach are in the left upper quadrant. The large intestines are in the lower quadrants, with the appendix in the right lower quadrant.

A patient with hepatitis could be expected to have an enlarged liver. Which quadrant would the nurse palpate to confirm this finding? A. Left upper quadrant B. Right upper quadrant C. Right lower quadrant D. Left lower quadrant

D. Secure the tubing to the patient's face with a transparent dressing. If a trauma patient has an injury that interferes with normal placement of the nasal cannula tubing, the tubing can be secured to the patient's face with tape or a transparent dressing. Placing both loops of the tubing over the patient's left ear would not hold the tubing in place. Placing netting over the patient's head would be irritating to the patient and would not secure the cannula in the correct position. The patient cannot be expected to lie totally still, and this position would not promote healing.

A patient with right ear trauma requires oxygen therapy with a nasal cannula. How should the nurse affix the tubing? A. Place both ear loops of the tubing around the patient's left ear. B. Place netting over the patient's head to hold the tubing in place. C. Instruct the patient to lie totally still to prevent the tubing from moving. D. Secure the tubing to the patient's face with a transparent dressing.

B. Apply oxygen via a nonrebreather mask. The nurse should apply oxygen via a nonrebreather mask. In the initial phase of care for injured patients, oxygen is never contraindicated, and insufficient oxygen administration may lead to hypoxia. The victim of a high-speed motor vehicle crash may have a serious internal injury, and the initial trauma assessment includes the administration of high-flow oxygen to maintain adequate oxygenation. Intubation is not considered at this time because the patient is able to breathe independently. After full evaluation and ruling out other serious injury, the oxygen administration may be reduced to a nasal cannula delivery, but the initial intervention is oxygen via a nonrebreather mask.

A patient with trauma from a high-speed motor vehicle crash has obvious leg fractures but is talking. The patient has an SpO2 of 91% and does not appear to have any difficulty breathing. What should the emergency nurse do when this patient arrives at the emergency department? A. Continue to monitor respiratory status and apply oxygen if the SpO2 drops below 90%. B. Apply oxygen via a nonrebreather mask. C. Place oxygen via a nasal cannula at 2 L/min. D. Prepare the patient for intubation in anticipation of respiratory compromise related to internal injury.

D. CDC website The CDC's website provides many educational information sheets and links related to fall prevention. The risk management department and the quality assurance nurse are not usually directly involved with patient education. The attending practitioner may be a good source for information but would likely refer the patient and family to the CDC or a similar organization.

A patient's family is concerned that the patient might fall at home. Which of these is an excellent reference for the patient and the family regarding falls? A. Attending practitioner B. Risk management department C. Quality assurance nurse D. CDC website

B. Returning the patient to a supine position and reporting a positive finding Because safety is always a priority, the patient should be returned to a supine position. Also, this patient's symptoms would be considered a positive finding: Weakness, dizziness, visual dimming, and a syncopal episode are all indications of cerebral hypoperfusion, which may be indicative of fluid loss. Once a positive finding has been determined, the orthostatic assessment of vital signs can be halted; continuing to assess vital signs, including blood pressure and heart rate, is not necessary.

A patient's supine vital signs are within normal limits. After moving from a supine to a standing position, the patient complains of feeling weak and dizzy. Which intervention is appropriate? A. Steadying the patient in the standing position until the symptoms subside and proceeding with vital sign readings B. Returning the patient to a supine position and reporting a positive finding C. Allowing the patient to sit down while vital sign readings are obtained D. Requesting additional help to steady the patient and attempting to obtain blood pressure and heart rate readings

A. Assess the patient's willingness to use nonpharmacologic pain-relief measures. Various nonpharmacologic interventions can help reduce pain and should be used with medications; the nurse should determine the patient's willingness to use them. Placing a patient prone and immediately initiating a back massage is not appropriate for all patients. Patients need their pain addressed proactively; telling a patient to lie in bed until the medication works is inappropriate. Administering a second pain medication immediately is unsafe.

A postoperative patient is continuing to report pain a few minutes after receiving pain medication. Which action should the nurse take? A. Assess the patient's willingness to use nonpharmacologic pain-relief measures. B. Immediately place the patient in a prone position and initiate a back massage. C. Explain that the patient should just lie in bed until the pain medication works. D. Immediately prepare and administer a second pain medication.

C. Teach the mother that pillows should be avoided. Pillows should be avoided with small infants because they can cause flexion of the airway and further compromise respiratory status. The mother should not obtain a pillow for the child. Infants who cannot sit independently need to be treated in a supine, not a prone, position. The orthopnea position should not be used unless the infant or child can assume it on his or her own.

A small infant in respiratory distress is in the emergency department. After the infant's condition stabilizes, her mother requests a pillow for her. How should the health care team member respond? A. Show the mother where the linen closet is. B. Teach the mother that the infant should be placed in a prone position. C. Teach the mother that pillows should be avoided. D. Show the mother how to place the infant in orthopnea position.

D. It may be erroneously elevated. Doppler ultrasound blood pressure readings in patients who have diabetes, are obese, or have calcified vessels may be erroneously elevated. Any necessary further treatment will depend upon the patient's baseline blood pressure and other clinical findings. A vasodilator is not warranted in this situation.

A systolic blood pressure measurement of 100 mm Hg is obtained from a patient with diabetes by using Doppler ultrasound. Which statement is correct regarding this blood pressure measurement? A. It indicates a need for a vasodilator. B. It may be erroneously low. C. It indicates the most accurate blood pressure. D. It may be erroneously elevated. Rationale: Doppler ultrasound blood pressure readings in patients who have diabetes, are obese, or have calcified vessels may be erroneously elevated. Any necessary further treatment will depend upon the patient's baseline blood pressure and other clinical findings. A vasodilator is not warranted in this situation.

D. Facilitation of the child's breathing The pediatric patient should be allowed to assume a position of comfort to decrease anxiety and facilitate spontaneous respiration. The most important consideration is the child's breathing. Allowing the child to assume the position of comfort, especially if on a family member's lap, facilitates easier respirations, decreases anxiety, and mitigates stress to the family member. Many procedures can be performed with the patient in the parent's lap, and ease of breathing is the overriding priority.

A young child in respiratory distress is sitting on his mother's lap. What should the health care team member expect this position to cause? A. Stress for the parent B. Undue anxiety for the child C. Interference with procedures D. Facilitation of the child's breathing

D. Perform a complete pain assessment and notify the practitioner. Having continued pain that exceeds the pain-intensity goal or more pain after receiving medication is unexpected, so a complete reassessment of pain is indicated along with a report to the practitioner. An analgesic should be effective within 1 hour of administration. Naloxone would reverse the effect of the pain medication. It is used to counter the effects of opioids used during surgery or in the case of an overdose; it does not control pain. Administering a higher dose of oxycodone does not mean the patient will become addicted to the opioid.

About 1 hour after receiving oral oxycodone, a patient states that continued pain exceeds the pain intensity goal and that the pain is "worse than it was before the medication." Which action should the nurse take? A. Explain to the patient that pain medication usually takes about 2 hours to be effective. B. Explain to the patient that a higher dose of medication would be addictive. C. Administer naloxone, a strong opioid antagonist. D. Perform a complete pain assessment and notify the practitioner.

D. Remove the sheath and further assess the penis for signs of impeded circulation Swelling, discoloration, and discomfort are signs that the condom catheter may be too tight and circulation may be compromised. The nurse should remove the sheath and assess the penis for additional signs of impaired circulation (e.g., discoloration) and ask the patient about any discomfort. The practitioner does not need to be notified immediately, but if swelling continues after the sheath is removed, the practitioner should be notified. Swelling is not normal with condom catheters. The nurse should not wait 30 minutes; immediate intervention is required.

After applying a condom catheter, the nurse checks the patient and notes penile swelling. What should the nurse do? A. Check the patient again in 30 minutes for discoloration of the penis B. Explain to the patient that some swelling is normal with condom catheters C. Notify the practitioner immediately D. Remove the sheath and further assess the penis for signs of impeded circulation

D. Snow gently falling on mountain tops Snow is a safe example because it does not involve a body of water. Having the patient think about water could potentially bring back memories of the near drowning, thereby causing additional anxiety. Images of the ocean, a lake, or waterfall may bring back these memories.

After completing the history and assessment of a patient, the nurse decides to use guided imagery to help decrease the patient's anxiety and pain. While taking the patient history, the nurse learned that the patient had a near-drowning experience 2 years ago. Which image is appropriate to use in guided imagery? A. Ocean water gently lapping at the warm sand B. Calm lake water glistening in the sun C. A large waterfall gliding down rocks D. Snow gently falling on mountain tops

D. The patient has a small reddened area on the heel. A reddened area on the patient's heel is an unexpected outcome. The nurse must minimize the risk by maintaining unrestricted circulation and correct patient body alignment while moving, turning, or positioning the patient. Retained ROM, skin that shows no evidence of breakdown, increased patient comfort, and proper body alignment are expected outcomes.

After moving the patient up in bed, the nurse should be concerned by which finding? A. The patient retains ROM. B. The patient's comfort level is increased. C. The patient is able to maintain proper body alignment. D. The patient has a small reddened area on the heel.

A. The oxygen tubing has been connected to the wrong gas. In haste, the nurse may have connected the oxygen tubing to the wrong gas line, and this could cause rapid patient deterioration. The nurse should always check to make sure that the tubing is connected to oxygen. A securely fitting oxygen mask, full inflation of the reservoir bag, and 300 psi in the oxygen tank are all favorable conditions for optimal therapy.

After quickly applying a nonrebreather oxygen mask to a patient with difficulty breathing, the nurse observes the patient's condition declining. What is the potential cause of this decline? A. The oxygen tubing has been connected to the wrong gas. B. The oxygen mask fits securely around the patient's mouth and nose. C. The oxygen reservoir bag was fully inflated. D. The oxygen tank has a reading of 300 psi.

A. Redness on the left elbow An unexpected outcome for positioning is the development of an area of redness or breakdown. The patient stating that she is comfortable is a goal as is having normal range of motion. The change in frequency is not an unexpected outcome; it is an intervention to avoid potential problems.

After repositioning an elderly patient from the lateral left side-lying position, the nurse documents the intervention. What should be documented as an unexpected outcome of this positioning? A. Redness on the left elbow B. The patient's statement indicating that she is comfortable C. Normal range of motion of the extremities D. A change in the frequency of repositioning

A. Redness of the patellar area of the right leg An unexpected outcome for positioning is the development of an area of redness or breakdown. The patient's statement that he or she is comfortable is an expected outcome. A normal ROM is also an expected outcome. A change in repositioning frequency is not an unexpected outcome but an intervention to avoid complications.

After repositioning an elderly patient, the nurse should document which finding as an unexpected outcome of the previous position? A. Redness of the patellar area of the right leg B. Patient's statement that he or she is comfortable C. Normal ROM of the extremities D. A change in repositioning frequency

D. Continue with the child's assessment The normal HR for a toddler ranges from 90 to 140 bpm; thus, there is no need to connect the toddler to a cardiac monitor, contact a practitioner, or administer medication until the nurse's assessment is complete.

An 18-month-old toddler is brought to the emergency department with a rash and runny nose. The child's apical pulse rate is 132 bpm, and the rhythm is regular. What is the appropriate nursing action? A. Administer medications to control the patient's HR B. Connect the toddler to a cardiac monitor to see the heart's rhythm C. Notify the emergency department practitioner immediately D. Continue with the child's assessment

C. She needs regular exercise, including walking. Increasing lower body strength and improving balance through regular physical activity may reduce the risk of falling. Sitting for long periods of time may lead to deconditioning, muscle atrophy, and pressure ulcers. Moving from side to side may help prevent pressure ulcers but does not prevent muscle atrophy and deconditioning. Physical therapy helps, but the benefits are minimal unless the patient takes part in her own care and begins to exercise and walk.

An older adult female patient is admitted from home. The nurse notes a small stage II pressure ulcer on the lower aspect of the patient's right buttock. When asked, the patient states that she has limited herself to sitting all day. She is afraid to walk since she fell last month. After arranging a physical therapy consult, what should the nurse tell the patient? A. She did the right thing because she might have fractured her hip. B. She should move around from side to side when sitting. C. She needs regular exercise, including walking. D. She need not worry because physical therapy can get her back in shape

C. Placing padding between the cannula and the skin In many cases, older adult patients have fragile skin, so the nurse should pad the skin to prevent breakdown. Taping the cannula to the skin may cause breakdown. Oxygen delivered via a nasal cannula should not be turned higher than 6 L/min, and the oxygen should be regulated according to the practitioner's order. The patient should not be instructed to remove the tubing because removal may cause hypoxia. The patient should be instructed to report whether the tubing becomes irritating.

An older adult patient requires placement of nasal cannula tubing for oxygen administration. Which action by the nurse helps to provide safe care to this patient? A. Taping the cannula to the patient's cheeks to secure it B. Turning the oxygen flow rate as high as it will go C. Placing padding between the cannula and the skin D. Instructing the patient to remove the tubing if it becomes irritating

B. The patient may tire quickly and need repositioning. Older adults in the orthopnea position are closely monitored because they may tire quickly and require additional support or repositioning. The orthopnea position should not increase dyspnea and may result in flexion, not extension, of the airway in the older adult with an altered mental status. The orthopnea position may create pressure on bony prominences, but it is not the most important reason to monitor the patient closely.

An older adult patient with dypnea is in the orthopnea position. Why should the patient be monitored closely? A. The position may worsen the dyspnea. B. The patient may tire quickly and need repositioning. C. The position may cause an extension of the airway. D. The position may create pressure on bony prominences.

D. Encourage the patient to allow the mind to drift and think about how pleasant relaxation is. The nurse should encourage the patient to allow his or her mind to drift and to feel relaxed to enhance the relaxation response and distract the patient from perceiving pain. The patient should breathe deeply to prevent the Valsalva response, which can increase intrathoracic pressure and compromise cardiac function. Sensations of tingling, heaviness, floating, and warmth are normal.

As a patient using progressive relaxation therapy completes each muscle group, what should the nurse do? A. Instruct the patient to notify the nurse immediately if any tingling sensations are felt. B. Encourage the patient to take shallow breaths. C. Instruct the patient to breathe out forcibly while the mouth and nose are firmly closed to stimulate a Valsalva response. D. Encourage the patient to allow the mind to drift and think about how pleasant relaxation is.

B. The importance of adequate dietary fiber intake For older adults, instituting a diet adequate in dietary fiber adds bulk, weight, and form to stool and improves defecation. In the absence of a physiologic reason to decrease fluid intake (e.g., history of heart or renal failure), decreasing the patient's fluid intake may increase constipation. Daily enemas may produce a dependency on enemas for defecation. Because of decreased ambulation from the hip surgery, postanesthesia state, and potential for constipation from pain medications, the patient continues to be at risk for a fecal impaction after discharge.

As part of discharge teaching for an older adult who had a fecal impaction during an inpatient stay for hip surgery, what should the nurse explain to the patient? A. The importance of limiting the daily fluid and water intake to four to six glasses a day B. The importance of adequate dietary fiber intake C. Nothing regarding the fecal impaction because constipation should not occur after discharge D. The importance of using an enema daily to prevent constipation

B. Fifth left ICS at the MCL Auscultation of the apical pulse is performed at the fifth left ICS at the MCL. The heart is located behind and to the left of the sternum, not to the right. The third ICS is too high in relation to the apex, where the apical pulse is assessed.

At which location should the nurse auscultate an adult's apical pulse? A. Third right ICS at the MCL B. Fifth left ICS at the MCL C. Third left ICS at the MCL D. Fifth right ICS at the MCL

C. The dependent shoulder tucked under In the Sims, or semiprone position, the dependent shoulder is lifted out rather than tucked under, thus keeping the shoulder in better alignment and preventing lateral neck flexion. A small pillow under the head prevents lateral neck flexion. A pillow under the flexed upper arm prevents internal rotation of the shoulder, and a sandbag or pillow parallel to the plantar surface of the foot helps maintain dorsiflexion of the foot, helping to prevent plantar contractions.

Before leaving a patient in the Sims position, the nurse should be concerned about which characteristic of his or her positioning? A. A small pillow under the head B. A pillow under the flexed upper arm C. The dependent shoulder tucked under D. A sandbag parallel to plantar surface of the foot

A. 0.4 Because this use of blow-by oxygen therapy does not allow contact between the oxygen delivery device and the patient's airway, much of the oxygen escapes into the atmosphere and does not benefit the patient. When the oxygen delivery source is set to 10 L/min during blow-by therapy, the maximum FIO2 the patient is likely to receive is 0.4. An FIO2 of 0.6, 0.8, and 1.0 is not possible using this method.

Blow-by oxygen therapy is initiated on a 2-year-old patient who is noncooperative with other traditional methods of oxygen delivery. This is facilitated by attaching oxygen tubing to an oxygen delivery source set to 10 L/min and held close to the child's face. What is the likely FIO2 that the child is receiving via this method? A. 0.4 B. 0.6 C. 0.8 D. 1.0

C. "My ABI was low. This means I may have a blocked artery." An ABI of 0.8 is low, not high. An ABI less than or equal to 0.9 correlates with peripheral arterial disease and may mean that one or more of the major arteries has more than 50% stenosis. A high ABI would be greater than or equal to 1.4 and could signify increased risk of mortality or cardiovascular disease.

Calculation of a patient's ABI has just been performed: the left leg ABI is 0.8. Which statement indicates that the patient understands the results? A. "My ABI was high. This means the chances of having a blockage are low." B. "My ABI was high. This means I may have a blocked artery." C. "My ABI was low. This means I may have a blocked artery." D. "My ABI was low. This means the chances of having a blockage are low."

B. Eye The patient who has had eye surgery may not be a candidate for controlled coughing because coughing increases intracranial pressure. Patients who have had surgery in the abdomen, chest, and pelvis should practice controlled coughing to prevent atelectasis and other postoperative complications.

Controlled coughing may be contraindicated if the patient has had surgery in which area? A. Abdomen B. Eye C. Chest D. Pelvis

B. Position the patient supine with the lower extremities elevated 15.2 to 30.5 cm (6 to 12 in). Elevating the lower extremities 15.2 to 30.5 cm (6 to 12 in) with the patient supine (i.e., the modified Trendelenburg position) is a quick treatment for symptomatic hypotension caused by hypovolemia, vasovagal reaction, or medication and may improve the blood pressure by improving venous return. The nurse can initiate this treatment without consulting an advanced care practitioner. The patient's position of choice may be detrimental, and a cool washcloth does not improve systemic perfusion. The Trendelenburg position, in which the head is lower than the body, places pressure on the diaphragm from the abdominal organs and may cause respiratory distress.

During a procedure, the patient complains of being light-headed. An assessment reveals pale, clammy skin and a blood pressure of 72/48 mm Hg. What should the nurse do? A. Contact the practitioner for further orders. B. Position the patient supine with the lower extremities elevated 15.2 to 30.5 cm (6 to 12 in). C. Position the patient supine and lower the head of the bed to the Trendelenburg position. D. Interrupt the procedure and let the patient assume a position of comfort, applying a cold washcloth to the forehead.

D. Patient routinely eats red meat twice a day. Red meat may cause false-positive test results when using the guaiac blood slide test. To confirm a positive test result, the nurse must repeat the test at least three times while the patient is on a meat-free, high-residue diet. For the slide test, the specimen should be taken from two different areas of the stool because occult blood from the upper GI tract is not always equally dispersed throughout stool. Caffeine intake and a vegetarian diet are not typically avoided before occult blood testing because they do not impact the test results.

During a routine preoperative assessment, a patient's stool specimen shows a positive result on the guaiac blood slide test. Why should the nurse question whether the occult blood test result is falsely positive? A. Patient has a high caffeine intake. B. Patient eats a vegetarian diet. C. Specimen was taken from two different areas of the stool. D. Patient routinely eats red meat twice a day.

C. A bruit in the carotid artery Narrowing of the carotid artery lumen by arteriosclerotic plaques causes disturbances in blood flow. Blood passing through the narrowed section creates turbulence and emits a blowing or swishing sound, called a bruit. The patient should be asked to hold the breath for a few heartbeats during carotid artery assessment so that respiratory sounds do not interfere with auscultation; the nurse should not hear breath sounds. Noise from the environment does not cause a blowing or swishing sound from the artery. An artery that is completely occluded does not have fluid movement sounds.

During an assessment of the carotid arteries, the nurse places the bell of a stethoscope over the left carotid artery and hears a blowing or swishing sound. The nurse should suspect that this sound is caused which phenomena? A. Breath sounds from the patient B. Artifact noise heard from the environment C. A bruit in the carotid artery D. A completely occluded carotid artery

A. Reposition the probe until loud, pulsatile sounds are heard. High-pitched sounds that resemble a rushing wind and are cyclic with respirations indicate that the probe is over a vein. To assess arterial flow, the probe should be repositioned until loud, pulsatile, pumping sounds are heard. The angle of the probe will improve signal reception but will not change the fact that the probe is over a vein. Cleaning the probe and skin will not change the quality of the sound; it will make the sounds easier to hear. The probe should never be cleaned with alcohol. A 2.25-MHz probe is used to assess fetal heart tones, not peripheral vessels.

During assessment of a patient's brachial pulse, a high-pitched sound is heard. The sound resembles a rushing wind and is cyclic with respirations. What is the best next step? A. Reposition the probe until loud, pulsatile sounds are heard. B. Increase the angle of the probe to 90 degrees. C. Clean the probe and the skin thoroughly with alcohol. D. Switch to the 2.25-MHz probe.

B. Attempt to locate the posterior tibial pulse. If the most distal pulse of an extremity cannot be located with a Doppler instrument, the next most proximal site should be assessed (posterior tibial in this situation). If no pulse can be detected there, continue moving proximally until blood flow is identified. Reapplying additional transmission gel should not be necessary. Pulse check progression, during evaluation for peripheral pulses, moves from the most distal to the most proximal sites. The popliteal pulse is not the next pulse in the move proximally. Blood flow is being evaluated in the left leg; evaluation of the right leg for comparison is not necessary at this time.

During assessment of peripheral pulses in the left leg via a Doppler instrument, the dorsalis pedis pulse cannot be located. What is the most appropriate next step? A. Attempt to find the dorsalis pedis pulse in the right leg. B. Attempt to locate the posterior tibial pulse. C. Attempt to locate the popliteal pulse. D. Reattempt to locate the pulse after applying additional transmission gel.

D. The abdomen is palpated before auscultation is done. The abdomen should be inspected first and then auscultated. Palpation and percussion of the abdomen should occur after inspection and auscultation because they can cause bowel sounds to be heard even when peristalsis is absent. Tenderness is determined by palpating the abdomen; inspection and auscultation should occur before palpation.

During orientation, a new nurse is performing an abdominal assessment. Which action indicates that further practice and study is needed? A. The abdomen is assessed for distention of the bowel before being palpated. B. The nurse determines any tenderness before touching the patient. C. Inspection is done before percussion. D. The abdomen is palpated before auscultation is done.

D. The patient's pain level Assessing the patient's pain level is important before teaching. The patient may need pain medication before teaching to perform IS appropriately. The patient's medication history is important but is not a priority before teaching. If the patient does not speak the nurse's primary language, an interpreter will be needed. The patient does not need to sit in a chair; he or she can sit in the bed.

During preparation for IS teaching, what should the nurse assess? A. The patient's medication history B. The patient's primary language C. The patient's ability to sit in a chair D. The patient's pain level

B. Recheck the right arm. Some patients feel anxious during blood pressure measurements and generate a higher blood pressure initially. The most appropriate next step is to recheck the brachial pulse in the right arm. The patient may have subclavian stenosis, but that is not determined until the systolic blood pressure in the right arm is rechecked. There is no reason to stop the ABI test in this case. The ABI is not calculated until a second right brachial pressure is obtained.

During pulse measurements to determine an ABI, the nurse obtains the following pressures: right brachial = 130 mm Hg, left brachial = 102 mm Hg. What is the most appropriate next step? A. Document subclavian stenosis. B. Recheck the right arm. C. Stop the ABI test. D. Calculate the ABI.

C. Request nutritional assessment and intervention from the registered dietitian. All patients who are identified during the admission process as malnourished or at risk for becoming malnourished should be referred to the registered dietitian, who can further evaluate them and ensure appropriate nutritional intervention and follow-up assessments. Watching the patient for several days may allow the level of malnutrition to increase. Ordering double portions for a patient with no appetite does not provide incentive for him or her to eat more. Waiting to start nutrition counseling until after discharge increases the patient's malnutrition risk.

During the admission nurse's assessment, the patient reveals a poor appetite for several weeks and a 4.5-kg (10-lb) weight loss. Which action should the nurse take? A. Order double portions on the patient's menu. B. Watch the patient for several days to further evaluate the loss of appetite. C. Request nutritional assessment and intervention from the registered dietitian. D. Refer the patient to outpatient nutrition counseling after discharge.

D. Ask the colleague to first help steady the patient while orthostatic vital signs are obtained. Older adults are more likely to be unsteady in the presence of dehydration, so it is helpful to have an assistant available in case the patient becomes syncopal. An assistant does not necessarily speed up the procedure, because the patient must still maintain the positions for the required time intervals; the primary reason for an assistant is to ensure the patient's safety. Painful procedures, such as initiating an IV line, should be deferred until vital signs have been taken. Oral fluids are contraindicated in some cases and should be deferred until a more complete assessment has been completed.

During the initial assessment of an older adult who is potentially dehydrated, a colleague comes into the room to assist and offers to start an IV line and draw laboratory samples. Which response is appropriate? A. Accept the assistance because it will speed the patient's care. B. Call the IV team to start the IV line and draw the blood. C. Give the patient fluids to drink until the IV line can be started. D. Ask the colleague to first help steady the patient while orthostatic vital signs are obtained.

B. A patient with a specific concern or current problem A focused assessment should be performed on a patient with a specific concern or current problem; before transferring a patient to another unit or facility; when receiving a patient from another unit; or when there is a change in physiologic or psychological status warranting a change in the level of care. A more in-depth assessment takes place upon admission and when a patient is transferred from another facility. A patient being transferred from a practitioner's office is treated as an admission.

For which patient would a focused assessment be appropriate? A. A newly admitted patient B. A patient with a specific concern or current problem C. A patient being transferred from a skilled nursing facility D. A patient being transferred from a practitioner's office

D. Three positive guaiac occult blood test results For confirmation of positive results, guaiac occult blood tests of stool must be repeated at least three times and must show positive results every time. A single positive guaiac test result does not confirm bleeding or indicate colorectal cancer. Fecal specimens should be taken from two different portions of the stool, using the blood slide test method because occult blood from the upper GI tract is not always equally dispersed throughout stool.

How does the nurse confirm a GI bleed when assessing the cause of an inpatient's anemia? A. A single positive guaiac occult blood test result B. Positive guaiac results in a single portion of a stool C. Two positive guaiac occult blood test results D. Three positive guaiac occult blood test results

A. Every 2 hours Repositioning is recommended every 2 hours for older adult patients. Every 4 hours, every 6 hours, and once a shift are not recommendations supported by research.

How often should the nurse reposition a 70-year-old patient? A. Every 2 hours B. Every 4 hours C. Every 6 hours D. Once a shift

A. Help the patient to a standing position if he is able. Men find it easier to empty the bladder while standing. Always determine mobility status before having a patient stand to void. If the patient is mobile, the standing position is preferred to using the sitting, side, and back positions and to elevating the head of the bed.

How should the nurse offer a urinal to a male patient who is permitted to get out of bed with assistance? A. Help the patient to a standing position if he is able. B. Encourage the patient to use the urinal in a sitting position. C. Assist the patient to a side or back position. D. Elevate the head of the bed to assist the patient.

C. Apply gentle pressure on the shaft to secure the catheter The nurse should apply gentle pressure on the penile shaft to secure a self-adhesive catheter. Adhesive tape may be inflexible and should not be used on a condom catheter because it may impede circulation. The self-adhesive sheath does not require moisture for application. A strip of elastic adhesive applied in a spiral fashion is used to secure condom catheters that are not self-adhesive.

How should the nurse proceed when applying a condom catheter with self-adhesive? A. Use a small amount of adhesive tape to ensure that the catheter is secure B. Spiral-wrap the penile shaft with a strip of elastic adhesive C. Apply gentle pressure on the shaft to secure the catheter D. Use a warm, wet cloth to ensure that the adhesive adheres

A. Turn the patient on the left side. Placing the patient on the left side may help identify anatomic landmarks and enhance the ability to hear heart sounds clearly. Standing up may alter the pulse rate. If an apical pulse is indicated, it should be obtained; the radial pulse can be compared, but the apical pulse still needs to be auscultated. The diaphragm of the stethoscope should be warmed to prevent the patient from being startled and to promote comfort.

If unable to palpate the PMI on a patient with serious heart disease, the nurse should take which action? A. Turn the patient on the left side. B. Ask the patient to stand straight and tall. C. Use the radial pulse reading instead of the apical pulse reading. D. Chill the diaphragm of the stethoscope.

A. Every hour while awake The nurse should ensure that the patient performs IS exercises at least 10 times an hour followed by controlled coughing every hour while awake or as directed by the practitioner. Every 2 or 4 hours is not frequent enough while every 30 minutes is excessive and may result in the patient becoming overtired.

In the absence of a specific order from the practitioner, how often should a postoperative patient perform IS? A. Every hour while awake B. Every 2 hours for the first 24 hours after surgery C. Every 4 hours while in the hospital D. Every 30 minutes for the first 24 hours then every 1 hour

A. Atelectasis Secretions accumulating in the airway may result in mucous plugging, atelectasis, and lobar collapse. Increased fluid intake and CPT help thin and clear these secretions, which can help reverse atelectasis. Empyema and pleural effusion are contraindications to CPT. Patients with congestive heart failure should not increase fluid intake.

Increased oral fluid intake combined with CPT is indicated for a patient experiencing which condition? A. Atelectasis B. Empyema C. Pleural effusion D. Congestive heart failure

B. Maintain the patient's known daily routine as much as possible. Patients who follow a consistent routine feel more secure, are less confused, and can better recognize safety hazards. Placing the patient at the nurse's station may be done in extreme situations only. If all side rails are up, this is considered a restraint, and patients may suffer life-threatening injuries climbing over them or off the foot of the bed. It may be helpful to have family members stay with the patient through the night if the patient is confused, but it is not necessary for most patients who are at risk of falling.

Knowing that a patient has a high risk of falls, the nurse reviews the preferred method of fall prevention. Which is the preferred method? A. Have a family member stay with the patient through the night. B. Maintain the patient's known daily routine as much as possible. C. Place the patient in a chair at the nurse's station so that the person is not likely to get up alone. D. Put all side rails up at bedtime to prevent the patient from getting up at night.

A. Measurement of all liquid (including IV) medications Measurement of all intake, including medications (e.g., oral, IV), is important for patients at risk for fluid imbalance abnormalities. Often medications are not included in intake. Patients with a potential fluid imbalance should be weighed every day on the same scale with the similar clothing. Restricting fluid intake is important for patients whose physical condition warrants restriction (e.g., renal failure, congestive heart failure) but is contraindicated in patients who may have a fluid deficit (e.g., febrile, diabetes ketoacidosis). Measuring urine output every shift (e.g., every 8 hours) is sufficient unless the patient is experiencing a critical event.

Nursing interventions for patients with the potential for fluid imbalance abnormalities include which action? A. Measurement of all liquid (including IV) medications B. Weighing of patients every other day C. Restriction of fluid intake D. Measurement of urine every hour

B. Hemoptysis Postural drainage can exacerbate active hemoptysis and is contraindicated for patients with this condition. Postural drainage is useful for patients with lung disease (e.g., recent pneumonia) and is the cornerstone of treatment for children with CF. Tube feedings are not a contraindication to postural therapy, but they should be stopped before therapy.

Postural drainage is contraindicated in a patient in which situation? A. CF B. Hemoptysis C. Recent pneumonia D. Tube feedings

A. A technique used to divert the patient's attention from the pain sensation Distraction is a technique that diverts a patient's attention away from the pain by introducing meaningful stimuli that refocus the patient's attention. Distraction is a technique (not a behavioral therapy) that can help decrease pain, but it does not cure pain. Distraction therapy does not focus on the reason the pain is occurring.

Providing a patient with pain relief may require pharmacologic and nonpharmacologic interventions. Which nonpharmacologic intervention is known as distraction therapy? A. A technique used to divert the patient's attention from the pain sensation B. A type of therapy used to cure pain C. A behavioral therapy that can decrease pain D. A technique used to help the patient understand why the pain is occurring

B. Intracranial pressure The Trendelenburg position has many potential negative effects because it increases intracranial and intraocular pressure, myocardial work, central venous pressure, and pulmonary venous pressure. This position decreases, not increases, peripheral perfusion of the lower extremities. The Trendelenburg position is known to reduce cardiac output, which decreases rather than increases cardiopulmonary performance, and studies are inconclusive as to its effect on cerebral perfusion pressure.

The Trendelenburg position can be detrimental because it may increase which factor? A. Peripheral perfusion of the lower extremities B. Intracranial pressure C. Cerebral perfusion pressure D. Cardiopulmonary performance

B. "Offering the urinal to your father at night will help prevent falls." Nocturia is common in older adults, so the nurse should offer the urinal at night to help prevent the patient from attempting to get out of bed to void, which could lead to a fall in an unfamiliar setting. Indwelling catheters are not inserted without a practitioner's order, and frequent nighttime voiding is not typically considered an indication for a urinary catheter. Waking the patient every hour is unnecessary and disruptive to his sleep pattern. The nurse should offer the urinal regularly throughout the night to avoid nighttime incontinence, whether the patient rings his call bell or not.

The daughter of an older male patient with slight dementia and occasional incontinence requests that the nurse not bother her father at night so he gets a good night's sleep. Which statement is an appropriate response? A. "I'll insert an indwelling catheter so your father can sleep through the night." B. "Offering the urinal to your father at night will help prevent falls." C. "Your father needs to be offered the urinal every hour during the night to prevent incontinence." D. "I'll go in your father's room only when he rings his call bell."

C. Decreased peristalsis Decreased peristalsis results in constipation for many older adults. Consumption of high-fiber foods and increased fluid intake are measures used to reduce constipation. Decreased abdominal tone is a normal finding in older adult patients but is not the main cause of constipation.

The most pronounced change in GI function in an older adult is constipation. What factor contributes to this problem? A. High fiber intake B. Increased fluid intake C. Decreased peristalsis D. Decreased abdominal tone

C. "Children who have been toilet-trained may regress when ill or when receiving IV fluids." Children who have been toilet trained may become incontinent because of the stress of being ill and because they are receiving IV fluids throughout the night. Attempts should be made to offer the urinal at appropriate times during the night. Bladder control usually returns to normal when the child is back on a home routine. Diapers should not be reintroduced to children who are toilet trained. The child's nocturnal incontinence is likely related to stress or IV fluids, not deliberately controlled by the child.

The mother of a 4-year-old child is worried that her toilet-trained child has been incontinent at night while an inpatient. Which is the best explanation to give to the mother? A. "Using diapers to prevent this problem is necessary while your child is a patient." B. "This is common, and you'll probably need to begin the toilet-training process again after discharge." C. "Children who have been toilet-trained may regress when ill or when receiving IV fluids." D. "Many young patients can be stubborn about this and have accidents on purpose."

B. A diet high in leafy green vegetables and green tea A diet high in leafy green vegetables and green tea does not increase the risk of VTE. Smoking and obesity do increase the risk of VTE. Patients who undergo prostate surgery have a greater risk of VTE than patients who undergo other types of surgery.

The nurse admits a patient who is anticipating a radical prostatectomy. What would not increase this patient's risk of VTE? A. Smoking two packs of cigarettes per day B. A diet high in leafy green vegetables and green tea C. Obesity with a body mass index of 42 D. Upcoming prostate surgery

C. The clearest pulse at the PMI When assessing the apical pulse, the nurse should place the diaphragm of the stethoscope over the PMI in the fifth ICS at the left MCL and auscultate for normal S1 and S2 heart sounds, which are not high pitched. The healthy adult should have an HR below 100 bpm and should not have arrhythmias.

The nurse assessing the apical pulse of a healthy adult should expect to hear which finding? A. Pulses at a rate of more than 100 bpm B. High-pitched S1 and S2 sounds C. The clearest pulse at the PMI D. Consistent mild arrhythmia

B. Presence of a fluid wave can be detected by using the nondominant hand. Palpation for a fluid wave should be made with the nondominant hand. If a fluid wave is felt, air is not causing the distention. Presence of a fluid wave indicates ascites, found in cirrhosis, peritonitis, metastatic carcinoma, ovarian carcinoma, and pancreatitis. In many cases, jaundice, pruritus, dependent edema, and enlarged superficial abdominal veins accompany ascites from liver congestion, not kidney obstruction.

The nurse concludes that the patient's abdomen is distended. In order to determine if fluid or air is causing distention, the nurse palpates for a fluid wave knowing what? A. Presence of a fluid wave indicates that air is causing the distention. B. Presence of a fluid wave can be detected by using the nondominant hand. C. Jaundice, pruritus, dependent edema, and enlarged superficial abdominal veins accompany ascites from kidney obstruction. D. Absence of a fluid wave indicates ascites.

B. "Cancer often causes bleeding in the lining of the GI tract." Cancer may cause bleeding in the lining of the GI tract, leading to a positive occult blood result. Fecal occult blood testing detects blood in the stool and is useful as a colorectal cancer screening test because cancers and adenomatous polyps bleed more than normal mucosa. The presence of cancer is not detectable in a specimen, and cancer does not change the DNA of the stool. Although some patients with cancer have GI bleeding, not all patients do.

The nurse explains to a patient that the occult blood test is used for colorectal cancer screening. The patient asks how blood in the stool can be used to diagnose cancer. Which response is the most appropriate? A. "The test changes color if cancer is present in the specimen." B. "Cancer often causes bleeding in the lining of the GI tract." C. "Cancer changes the DNA of the stool, and these changes are detectable with this test." D. "All patients with cancer excrete blood in the stool."

C. 30 to 60 degrees For semi-Fowler position, the head of the bed is raised 30 to 60 degrees. For Fowler position, it is raised 60 to 90 degrees. For low-Fowler position, it is raised 15 to 30 degrees. Unless contraindicated, the nurse may raise the patient's legs 10 to 15 degrees with a pillow to promote comfort.

The nurse has an order to put the patient in a semi-Fowler position. How high should the nurse raise the head of the bed? A. 15 to 30 degrees B. 60 to 90 degrees C. 30 to 60 degrees D. 5 to 15 degrees

B. The TUG test The TUG involves looking for unsteadiness and is used to screen for altered balance and gait. Homans sign is a test for venous thrombosis. DAME is an acronym used to help determine whether a patient has a history of falls or other injuries at home. There is no test known as the Orthostatic Hypotension Omission test.

The nurse is assessing a patient for fall risk. The nurse gives instructions to sit in a chair and then for the patient to get up without using arms, walk a few feet, and sit in the chair. What is the name of this test? A. Orthostatic Hypotension Omission test B. The TUG test C. DAME test D. Homans sign

C. "I should wear them alone or with antiembolic stockings." SCDs can be used alone or in conjunction with antiembolic stockings, depending on the practitioner's preference. SCDs are worn both day and night but should be removed periodically, at least once per shift.

The nurse provided a patient education on SCD use. Which statement suggests that the patient understands when SCDs are to be used? A. "I should only wear them at night when sleeping." B. "I should wear them 24 hours a day." C. "I should wear them alone or with antiembolic stockings." D. "I should wear them only in the daytime because the noise keeps me awake at night."

D. Generalized protein-calorie malnutrition In many cases, weight loss and muscle wasting, along with dull, shedding hair that is easily pluckable, are signs of generalized protein-calorie malnutrition. Refeeding syndrome is characterized by acute electrolyte shifts when nutrition has been resumed after having inadequate nutrition for an extended period of time. Cardiomyopathy can be caused by inadequate selenium intake. In many cases, rickets, bone pain, and osteomalacia are the result of inadequate vitamin D intake.

The nurse is assessing a patient's nutritional status. The patient has been losing a large amount of weight and demonstrates muscle wasting, and the patient's hair is dull. These findings may be attributed to which condition? A. Refeeding syndrome B. Inadequate selenium intake C. Inadequate vitamin D intake D. Generalized protein-calorie malnutrition

B. Redness, swelling, warmth, and tenderness of an extremity Redness, swelling, warmth, and tenderness of an extremity are signs and symptoms of a thrombus. The patient's sensitivity to temperature is not a sign of a possible thrombus. Coolness of an extremity may indicate decreased perfusion of an extremity. Jaundice of an extremity does not indicate a thrombus but may indicate that the patient is experiencing liver involvement.

The nurse is assessing a postsurgical patient for thrombus. What symptoms might a patient who has a thrombus experience? A. Increased temperature sensitivity of an extremity B. Redness, swelling, warmth, and tenderness of an extremity C. Coolness of an extremity D. Jaundice color of an extremity

B. The patient is at ideal body weight. The patient is at his ideal body weight; he is not obese, overweight, or underweight. The calculation of ideal body weight for a male uses the following formula: 48.1 kg (106 lb) for the first 152.4 cm (5 ft), plus 2.7 kg (6 lb) per additional 2.5 cm (1 in). For the first 152.4 cm (5 ft) of height, this patient is allowed 48.1 kg (106 lb); for the next 35.5 cm (14 in) of height, he is allowed 2.7 kg (6 lb) per inch, or 38 kg (84 lb): 106 + 84 = 190. ??????? wtf

The nurse is assessing the nutritional status of a 32-year-old man who is 188 cm (6 ft 2 in) tall and weighs 86 kg (190 lb). What do these data indicate? A. The patient is obese. B. The patient is at ideal body weight. C. The patient is overweight. D. The patient is underweight.

A. Surgical placement of a filter in the IVC The nurse should anticipate the surgical placement of a filter in the IVC. This procedure is indicated for patients who have recurrent DVT, are at high risk for PE, are intolerant of anticoagulation therapy, or are not compliant with anticoagulation therapy. A filter provides a barrier against an embolus from the lower extremities through the IVC. Prolonged bed rest is contraindicated because it increases the risk of DVT. Lifetime treatment with IV heparin is not feasible, and amputation of the affected extremity is not indicated.

The nurse is caring for a patient being treated for DVT for the third time. This patient cannot perform subcutaneous injections at home and is not compliant with an oral warfarin regimen. What other treatment options should the nurse anticipate that the practitioner will order? A. Surgical placement of a filter in the IVC B. Prolonged bed rest C. Lifetime treatment with IV heparin D. Amputation of the affected extremity

B. In a normal resting position with the wrist slightly extended The nurse should position the patient's flaccid hand in a normal resting position with the wrist slightly extended. The arches of the hand should be maintained with the fingers partially flexed, not extended. A rolled washcloth placed in the patient's clasped hands may be used as well. A spastic hand, not a flaccid hand, should be positioned with the wrist in a neutral position or slightly extended; fingers should be extended with the palm down, not up, or they may be placed in a relaxed position with the palm up. Therapeutic braces and splints as prescribed may also be used to maintain proper alignment.

The nurse is caring for a patient with a flaccid hand. In which position should the nurse place the hand? A. With the arches of hand maintained and the fingers extended B. In a normal resting position with the wrist slightly extended C. In a neutral position with the fingers extended D. In a relaxed position with the palm up

D. A smooth rounded mass at the symphysis pubis A full bladder results in a smooth mass above the symphysis pubis. A fluid wave indicates the presence of ascites. Tenderness at the costovertebral angle indicates kidney inflammation. Midline dull epigastric pain is indicative of a gastric ulcer.

The nurse is caring for a patient with an indwelling urinary drainage catheter. The nurse suspects the catheter is obstructed. Which finding would confirm the nurse's suspicions? A. Midline dull epigastric pain B. A fluid wave verified by ultrasound examination C. Tenderness at the costovertebral angle D. A smooth rounded mass at the symphysis pubis

A. Warmth Warmth, heaviness, floating, and tingling are sensations that the patient may experience during the relaxation technique. These sensations occur because of diminished sympathetic nervous system arousal. Coldness, mild pain, and mild anxiety are not sensations typically experienced during the relaxation technique.

The nurse is describing progressive relaxation as a nonpharmacologic intervention to a patient. What should the nurse say that the patient may experience during the procedure? A. Warmth B. Coldness C. Mild pain D. Mild anxiety

B. LDL cholesterol is the major component of atherosclerotic plaques. LDL particles deliver fat molecules to cells, and in high concentrations, they can drive the progression of atherosclerosis. Desirable cholesterol levels are less than 200 mg/100 ml. LDL levels should be less than 130 mg/dl for adults and less than 110 mg/dl for children. HDL levels should be more than 45 mg/dl for males and more than 55 mg/dl for females.

The nurse is educating a patient on the importance of monitoring cholesterol levels and knowing the numbers. What information is appropriate to give to the patient? A. Normal cholesterol levels are less than 300 mg/100 ml. B. LDL cholesterol is the major component of atherosclerotic plaques. C. LDL levels should be less than 200 mg/dl for adults. D. HDL levels should be more than 100 mg/dl.

B. Inability to help move up in bed Rationale: The inability to help move up in bed is not a risk factor for a complication from immobility; however, it needs to be considered when positioning the patient. Decreased sensation or paralysis in the immobile patient increases the risk of pressure injury. The older adult has a higher risk of complications from immobility.

The nurse is evaluating a patient before placing him in a supported Fowler position. Which circumstance would the nurse know is not a risk factor for a complication from immobility? A. Decreased sensation to legs B. Inability to help move up in bed C. Paralysis from the waist down D. Being 92 years old

B. DVT Patients who are immobilized for several days or hours or who have had surgery, joint replacements, heart failure, shock, varicose veins, or leg pain are at high risk for impaired tissue perfusion resulting in DVT. Unilateral edema of the affected leg is the most common physical finding of DVT. Muscle fatigue presents in a more generalized manner and does not result in warm and swollen extremities. Arthritis causes pain and swelling at the joints, not the calf muscles. Peripheral vascular disease represents a broad group of abnormalities that cause cool extremities.

The nurse is examining a patient who has just returned home after an 8-hour plane trip. The patient is complaining of leg pain, and his left calf muscle is unilaterally heated, firm, and swollen. The nurse suspects that the patient had developed which problem? A. Muscle fatigue B. DVT C. Inflamed arthritis D. Peripheral vascular disease

B. Ask the patient to perform a return demonstration. A return demonstration determines whether the patient can perform IS correctly. Documentation in the patient's chart, keeping the IS within the patient's reach, and encouraging the patient to perform IS exercises is important; however, knowing whether the patient can perform IS correctly is most important.

The nurse is finished teaching the patient how to perform IS. What is the nurse's next action? A. Document the patient's volume achieved in the chart. B. Ask the patient to perform a return demonstration. C. Keep the incentive spirometer within the patient's reach. D. Ensure that the patient performs IS exercises at least 10 times an hour.

B. Measure the legs using a flexible tape measure. Measure the patient's legs using a flexible tape measure to determine the proper size for antiembolic stockings and SCD sleeves. Each leg is measured separately. Measurements should be taken in the morning because swelling of the extremities tends to increase throughout the day and could alter measurements. The length of the thigh is measured as well as the circumference of the thigh and the calf at the greatest dimension.

The nurse is measuring for antiembolic stockings on a 65-year-old postoperative patient. Which criterion does the nurse use? A. Measure the right leg to determine the size for both extremities. B. Measure the legs using a flexible tape measure. C. Take measurements in the evening if possible. D. Measure the length of the calf.

A. Older adults may experience muscle wasting, so they require careful measurement. Older adults may experience muscle wasting because of the aging process; therefore, it is essential to measure the legs carefully to ensure proper fit. Antiembolic stockings may be used alone or with SCDs, according to the practitioner's preference. Older adults have decreased venous return because of the loss of fat stores. The age of the patient has no bearing on wrinkled stockings.

The nurse is ordering antiembolic stockings for an older postop adult patient. What should the nurse remember? A. Older adults may experience muscle wasting, so they require careful measurement. B. Older adults require SCDs along with antiembolic stockings. C. Older adults usually have enhanced venous return because of the loss of fat stores. D. It is almost impossible to get wrinkles out of the stockings of older patients.

B. "Breathe comfortably and refrain from speaking." Auscultation requires the examiner to isolate each heart sound at all sites without interference from background noise such as talking. The patient should be in a restful position. Taking deep breaths or holding respirations interferes with the nurse's ability to auscultate heart sounds.

The nurse is preparing to auscultate the patient's heart sounds. Which instruction should the nurse give the patient? A. "Say your name repeatedly." B. "Breathe comfortably and refrain from speaking." C. "Walk in place and take deep breaths." D. "Bend the knees and hold your breath."

D. Contact the practitioner to request additional orders. f fecal impaction is detected, contacting the practitioner and awaiting further instructions regarding need for digital disimpaction is the most appropriate action versus irrigation or enema to evacuate the rectal vault. Irrigation may help, but additional orders are needed before the rectum is evacuated and the fecal containment device is inserted. Inserting the fecal containment device with impacted stool in the rectal canal would be difficult. Stool impaction is not an absolute contraindication for insertion of a fecal containment device, but disimpaction or evacuation must occur before the device can be inserted to assist with fecal management and containment.

The nurse is preparing to insert an indwelling fecal containment device. During the initial digital rectal examination, the nurse notices hard stool in the rectal vault that indicates fecal impaction. Which action is the most appropriate in this situation? A. Alert the patient that insertion is contraindicated because of stool impaction. B. Irrigate the rectal vault with 1000 ml of water. C. Insert the device and then irrigate to break up the stool. D. Contact the practitioner to request additional orders.

A. Accurate measurement leads to optimum stocking pressure that encourages circulation. The patient's measurements are compared with the manufacturer's sizing chart. Applying the correct size device assists in achieving optimum stocking pressure. This change in pressure produces the greatest increase in venous flow velocity that is both safe and practical. Height and weight are not measured for the purpose of antiembolic stocking or SCD application. Proper fit may ensure easier application of the devices, but that is not the main therapeutic purpose of correct measurements. If the stockings do not cover the toes, the elastic at the toe can cause constriction and reduced circulation.

The nurse is preparing to measure a patient for antiembolic stockings and SCDs. What is the most important reason for the nurse to determine accurate sleeve size? A. Accurate measurement leads to optimum stocking pressure that encourages circulation. B. Height and weight affect calf circumference. C. Proper fit ensures ease of application. D. Proper fit ensures that toes remain uncovered for circulation assessments.

C. Ensure that the patient has a small pillow supporting his or her head. Too many pillows may cause or worsen a neck flexion contracture by keeping the head in extreme flexion. The head of the bed should be elevated 60 to 90 degrees. Pillows should be placed to support the affected side, not the unaffected side. The feet should be maintained in dorsiflexion to prevent plantar flexion contractures.

The nurse is repositioning a 67-year-old patient with right-sided hemiplegia to a supported Fowler position. Which action should the nurse take? A. Place pillows on the unaffected side for support. B. Elevate the head of the bed 20 to 30 degrees. C. Ensure that the patient has a small pillow supporting his or her head. D. Ensure that the feet are maintained in the toe-down position (extended).

B. I need to call my mom to help me reposition him in the bed. At least three people should reposition an obese patient weighing more than 200 pounds to make positioning easier and to protect the healthcare workers or family members from injury. Removing the pillows from the bed allows for easier movements and positioning. Asking the patient to assist when he is able is appropriate and determining the patient's level of pain allows for the administration of medication if needed before the repositioning.

The nurse is teaching a family member how to reposition her elderly, 300-pound father in bed. Further teaching would be needed if the family member made which statement? A. I need to remove the pillows from the bed before repositioning my dad. B. I need to call my mom to help me reposition him in the bed. C. I will ask my dad to help when I reposition him in the bed. D. I will check if he is in pain before I start repositioning him.

B. Perform postoperative leg exercises with the unaffected extremity Extremities unaffected by surgery may be safely exercised unless otherwise indicated by the practitioner. The nurse should instruct the patient to turn from side to back to the other side every 2 hours while awake. The nurse should tell the patient to repeat individual leg exercises as ordered by the practitioner.

The nurse is teaching a patient who had surgery on the left leg how to do postoperative leg exercises. What should the nurse tell the patient to do? A. Turn four times per day during the first 48 hours after the operation B. Perform postoperative leg exercises with the unaffected extremity C. Complete leg exercises on both legs once daily D. Repeat individual leg exercises 20 times per day

B. Under the upper back Supporting a supine patient under the upper back leaves the neck and head unsupported and out of a neutral alignment. Placing pillows under the calves keeps the ankles off the bed. Placing pillows under the lumbar area supports the lower back. Placing pillows under the forearms supports the arms in a neutral position.

The nurse is teaching family members how to support their mother in the supine position. The patient is 81 years old and has decreased mobility in her lower extremities. The nurse knows the family requires additional teaching if they support the patient in which area? A. Under the calves B. Under the upper back C. Under the lumbar area D. Under the forearms

A. Have the patient wear high-top sneakers. High-top sneakers maintain the foot in dorsiflexion, which prevents plantar flexion contractures. Massage lotion and ankle rolls are important measures to maintain skin integrity but do not prevent plantar flexion contractures. An immobile patient requires repositioning every 2 hours. Repositioning does not prevent plantar flexion contractures unless measures are taken to maintain the feet in dorsiflexion.

The nurse is teaching family members to care for an older adult patient. To prevent plantar flexion contractures, the nurse should teach the caregivers to implement which intervention? A. Have the patient wear high-top sneakers. B. Apply massage lotion to the patient's feet daily. C. Place a small roll under the patient's ankle. D. Reposition the patient every 6 to 8 hours.

B. Keep the ball in the IS elevated for as long as possible The goal is to keep the ball elevated for as long as possible, ensuring maximal sustained inhalation to improve lung expansion with minimal risk of alveolar collapse. The patient should exhale normally. A quick snap to the top of the chamber with a rapid, very brief, low-volume breath or inhaling quickly does not achieve maximal sustained inhalation.

The nurse is teaching the patient how to perform IS. What is the correct method to teach the patient when performing IS? A. Inhale quickly. B. Keep the ball in the IS elevated for as long as possible. C. Exhale slowly. D. Breath quickly to get the ball elevated.

D. "I will monitor the pH of the feces." Monitoring the pH of feces has no benefit; typically, pH does not change and does not alter the care required for the patient. Continued assessments of the patient, perineal skin, and fecal drainage are performed to detect the development of pressure ulcers that may prolong the patient's hospitalization. If diarrhea is excessive, fluids and electrolytes may be lost in the feces, resulting in dehydration and electrolyte imbalances. The amount and consistency of fecal drainage should be evaluated; the migration of the catheter or a change in fecal consistency may indicate that the indwelling fecal containment device is obstructed.

The nurse is training a graduate nurse new to the unit. After placing an indwelling fecal containment device, both nurses discuss further monitoring and the patient's care related to the device. Which statement indicates that the graduate nurse requires further teaching? A. "I will assess the patient's perineal skin and monitor for leakage." B. "I will monitor fluid and electrolyte balance." C. "I will assess the amount and consistency of fecal drainage." D. "I will monitor the pH of the feces."

D. To promote venous return and prevent venous pooling Antiembolic stockings help reduce two of the causes of VTE formation. They promote venous return by maintaining pressure on superficial veins to prevent venous pooling, thereby reducing the risk of clot formation in the lower extremities. They also prevent passive dilation of the veins, thereby decreasing the risk of endothelial tears. Antiembolic stockings do not decrease blood flow through the legs, increase venous dilation, or apply pressure to damaged vessels and promote clotting. The purpose of antiembolic stockings is to prevent clots, not to cause them.

The nurse knows that applying antiembolic stockings to the legs of a patient at risk for VTE is done for which reason? A. To decrease blood flow through the legs B. To reduce the risk of venous tears through passive venous dilation C. To apply pressure to damaged vessels and promote clotting D. To promote venous return and prevent venous pooling

A. Instruct the patient to sit and rest before apical pulse assessment. If the patient has been smoking, the nurse should allow him or her to sit and rest before pulse assessment so true baseline can be assessed. Walking briskly would likely increase the pulse rate. The environment should be quiet during apical pulse assessment so the nurse can hear the heartbeat accurately. The patient should not be given supplemental oxygen; instead, the nurse should educate the patient about smoking cessation.

The nurse needs to assess the apical pulse of a patient who just finished smoking a cigarette. How should the nurse proceed? A. Instruct the patient to sit and rest before apical pulse assessment. B. Ask the patient to walk briskly for 3 minutes to cleanse the cigarette smoke from his or her lungs. C. Begin the pulse assessment and ask the patient questions during the procedure. D. Administer oxygen for 5 minutes to bring heart function back to baseline.

A. Reinforce to the patient that an overfilled collection bag may create unnecessary tension on the catheter The nurse should teach the patient that a collection bag that fills completely may put unnecessary tension on the catheter and may cause the catheter to come off. Although the bag should be emptied regularly, hourly emptying is unrealistic. Instructions about hanging the bag on the wheelchair and kinks in the tubing are important but are not related to concerns about an overfilled bag.

The nurse notes that a patient who is about to be discharged with a condom catheter is letting his collection bag fill completely. What should the nurse do? A. Reinforce to the patient that an overfilled collection bag may create unnecessary tension on the catheter B. Reinforce to the patient that the tubing should be checked for kinks regularly C. Instruct the patient to empty the bag hourly D. Instruct the patient not to hang the bag from his wheelchair

C. Ask the parent for input regarding the infant's pain intensity. A quiet and withdrawn infant who has received pain medication may not necessarily be pain free. Parents may be a helpful source of information when assessing a child's pain and when planning pain-relief therapies because most parents know how their child exhibits pain and whether pain-relief interventions have been successful. Infants and children respond to pain differently than adults; although some may cry and thrash about, others may be quiet and withdrawn. A 6-month-old infant does not have the verbal skills to use the Wong-Baker FACES Pain Rating Scale. Without further assessment, the nurse should not request an increased analgesic dose for the infant.

The nurse notices that a 6-month-old infant who received pain medication during the previous shift is now quiet and withdrawn. In completing the pain assessment, what should the nurse should do? A. Indicate that the infant's pain intensity is "0." B. Request that the practitioner increase the infant's analgesic dose immediately. C. Ask the parent for input regarding the infant's pain intensity. D. Assess the infant's pain intensity further using the Wong-Baker FACES® Pain Rating Scale.

C. "You need to continue drinking adequate amounts of fluid to maintain your urinary health." Patients with urinary problems may be hesitant to drink fluids for fear of incontinence or increased urinary frequency, so educating them about the importance of fluid intake for maintaining urinary health is vital. Fluid intake should not be limited. To prevent urinary stasis, patients should void when they feel the urge. Caffeinated drinks may increase, not decrease, urinary frequency.

The nurse notices that a female patient with urinary frequency has been limiting her fluid intake. Which instruction should the nurse give the patient? A. "Limiting fluids helps decrease your urinary frequency, which allows you the opportunity to sleep through the night." B. "Try to avoid the urge to void for as long as possible to decrease your urinary frequency." C. "You need to continue drinking adequate amounts of fluid to maintain your urinary health." D. "Try drinking a beverage with caffeine to decrease your urinary frequency."

D. Performing a series of short inspirations The patient who performs a series of short inspirations during IS requires more education; the correct procedure is to maintain a constant flow. Sputum should be examined for its consistency, amount, and color changes. It is correct to seal the lips completely over the mouthpiece. The correct procedure is to achieve maximum inhalation, hold the breath for at least 5 seconds, and then exhale normally.

The nurse observes a patient's return demonstration of IS. Which patient action indicates that additional education is needed? A. Examining expectorated sputum B. Completely sealing his or her lips over the mouthpiece C. Holding the breath after maximum inhalation D. Performing a series of short inspirations

A. Chronic arterial insufficiency Classic signs of chronic arterial insufficiency in the lower extremities include pale, cool, thin, and shiny skin with reduced hair growth. Nail beds on the feet are thickened. Symptoms of DVT include leg pain and warm, firm, and swollen legs. Hypotension may result in dizziness, lightheadedness, and faintness. Murmurs may cause fainting but do not affect the lower extremities.

The nurse performing a physical examination notices that the skin of the patient's lower extremities is pale, cool, thin, and shiny. The patient's nails are thickened, and there is little hair growth on the extremities. The nurse should consider that the patient may have which problem? A. Chronic arterial insufficiency B. Hypotension C. Heart murmur D. DVT

C. "We should use his brace for positioning when his leg gets stiff." The brace, boot, or splint should be used routinely and not just when stiffness or a change in range of motion is observed. Proper positioning promotes comfort and helps avoid pressure injuries. Using at least two people to reposition a patient makes the procedure easier on the patient and protects the caregivers from injury.

The nurse recognizes that additional family and patient education is necessary when a family member makes which statement regarding positioning of her elderly father who is in the Sims position? A. "Keeping dad positioned correctly will help him be more comfortable." B. "Changing dad's position frequently will help avoid pressure ulcers." C. "We should use his brace for positioning when his leg gets stiff." D. "We need to have at least two people to move dad into a different position."

C. We should use her brace for positioning when her foot gets stiff. A brace, boot, or splint should be used routinely and not just when stiffness or a change in ROM occurs. Proper positioning promotes comfort and helps avoid pressure injuries. Using at least two people to reposition a patient makes the repositioning easier on the patient and protects the caregivers from injury.

The nurse recognizes that additional family and patient education is necessary when a family member makes which statement regarding positioning of the hemiplegic patient in the prone position. A. Making sure mom's position is correct will help make her more comfortable. B. Changing mom's position frequently will help avoid pressure ulcers. C. We should use her brace for positioning when her foot gets stiff. D. We need at least two people to move mom to a different position.

D. Rebreathing carbon dioxide Setting the flow rate too low may collapse the reservoir bag and cause the patient to rebreathe carbon dioxide. Setting the flow rate too low does not cause pressure injuries. If carbon dioxide is allowed to accumulate, the patient is at risk for hypo-oxygenation, not hyperoxygenation. Because of the decreased oxygen intake, there is no risk in this case for oxygen-induced hypoventilation.

The nurse sets the oxygen flow rate too low for use with a nonrebreather mask. What risk does this pose to the patient? A. Pressure injuries on the face B. Hyperoxygenation C. Oxygen-induced hypoventilation D. Rebreathing carbon dioxide

A. Digoxin Apical pulse assessment would be appropriate for a patient taking digoxin, which is a cardiac medication that affects the heart rate and rhythm. Omeprazole is an anti-ulcer medication and does not have significant cardiac effects. Acetaminophen, an analgesic, does not have cardiac effects. Gabapentin is an anticonvulsant and does not have significant cardiac effects.

The nurse should instruct family members how to assess the apical pulse of an elderly relative taking which medication? A. Digoxin B. Omeprazole C. Acetaminophen D. Gabapentin

C. Joint mobility worsens. The family should be taught to reposition the patient more frequently if joint mobility becomes impaired or worsens, pressure areas begin to appear, or the patient complains of discomfort. As mobility increases, the need to reposition the patient does not increase. Repositioning should be more frequent when the patient is experiencing discomfort. Repositioning needs are not affected by the presence of a urinary catheter.

The nurse should teach family members to reposition a patient more frequently when which situation occurs? A. Pain is resolved. B. Mobility begins to improve. C. Joint mobility worsens. D. A urinary catheter is placed.

B. To prevent postoperative pulmonary complications An incentive spirometer is most commonly used after abdominal or thoracic surgery to help reduce the incidence of postoperative pulmonary atelectasis. The goal is for the patient to return to preoperative lung function, not to improve lung function. Peak flow is measured with a peak flow meter or pulmonary function testing. Aerosolized medications are administered via a metered dose inhaler or nebulizer.

The nurse walks into a patient's room with an incentive spirometer, and the patient asks, "What's the purpose of that?" The nurse should provide which answer? A. To administer aerosolized medications B. To prevent postoperative pulmonary complications C. To measure patient peak flow D. To improve lung function

D. The patient's past pain experiences, values, cultural expectations, and emotions The pain experience is a product of the patient's past pain experiences, values, cultural expectations, and emotions. The amount of opioid analgesic the patient can tolerate without oversedation, the extent of the surgical procedure, and the age and weight of the patient are important, but secondary, considerations.

The pain experience is primarily a product of what? A. The patient's age and weight B. The amount of opioid analgesic the patient can tolerate without oversedation C. The extent of the surgical procedure D. The patient's past pain experiences, values, cultural expectations, and emotions

B. 35 pack-years Pack-years are calculated by multiplying the number of packs consumed per day by the number of years smoked. Therefore, 1.5 packs per day × 10 years = 15 pack-years, and 2 packs per day × 10 years = 20 pack-years, making the total 35 pack-years. Although the patient smoked for 20 years, the correct response is not 20 pack-years. It is important to note whether the patient had quit smoking and for how many years. However, this does not reduce the pack-year amount.

The patient smoked 1.5 packs of cigarettes daily for 10 years and increased to 2 packs a day for 10 years. The patient quit smoking 20 years ago. How many pack-years would the nurse calculate the patient has smoked? A. 30 pack-years B. 35 pack-years C. 15 pack-years D. 20 pack-years

A. Slow, deep respirations, a calm facial expression and voice, and a relaxed posture When a nonpharmacologic technique is successful, the patient is relaxed and comfortable afterward as evidenced by slow, deep respirations; calm facial expressions and tone of voice; and relaxed muscles and posture. Patients who have uncontrolled pain are commonly noncompliant with treatment and are agitated or angry. Patients in pain constantly turn and reposition themselves in bed in an attempt to achieve a comfortable position.

The postoperative nurse is assessing whether a nonpharmacologic technique has effectively helped the postoperative patient control pain. Which behavior indicates that the intervention was successful? A. Slow, deep respirations, a calm facial expression and voice, and a relaxed posture B. Unwillingness to get out of bed and ambulate C. Pacing the floor and speaking in loud, angry tones D. Constant turning and repositioning in bed

A. Supervise and aid assistive personnel with this responsibility. To ensure that the spinal column is kept in alignment during the procedure, the nurse should always supervise and aid assistive personnel when a practitioner orders log rolling for a patient. Delegating the log rolling procedure is not appropriate nursing practice. Three health care personnel should perform log rolling; therefore, a nurse and two health care assistants are needed. Log rolling should begin as soon as ordered to prevent skin breakdown.

The practitioner has written an order for a patient with recent spinal surgery to be log rolled every 2 hours. Which action should the nurse take? A. Supervise and aid assistive personnel with this responsibility. B. Delegate the log-rolling task to experienced assistive personnel. C. Perform the log rolling every 2 hours with one assistive person. D. Wait until the patient is able to assist before implementing the order.

B. The affected arm away from the body and the elbow extended with the palm up In a hemiplegic patient, the affected extremity should be positioned to maintain mobility in the arm, joints, and shoulder. The affected arm should be away from the body with the elbow extended and the palm facing up. Keeping the arm close to the body and the elbow flexed counteracts and limits the arm's ability for external rotation.

The student nurse is positioning a hemiplegic patient in a supported Fowler position. Which position of the upper extremity would the nursing instructor expect to see? A. The affected arm close to the body and the elbow flexed with the palm down B. The affected arm away from the body and the elbow extended with the palm up C. The unaffected arm close to the body and the elbow flexed with the palm down D. The unaffected arm away from the body and the elbow extended with the palm up

B. What the pain feels like Pain quality is best evaluated with open-ended requests, such as "Tell me what your pain feels like." The pain region and pattern of radiation are assessed by asking the patient where the pain occurs. Provocative and palliative factors of pain are assessed by asking the patient what makes the pain better or worse. Pain timing is evaluated by asking the patient whether the pain is constant, intermittent, continuous, or a combination of those.

To assess pain quality, which of these should the nurse ask the patient to describe? A. Where the pain is B. What the pain feels like C. What makes the pain better or worse D. Whether the pain is constant, intermittent, continuous, or a combination

B. Provide perineal care more frequently. Patients at risk of acquiring an infection need perineal care more frequently than just with the daily bath. These patients include those with fecal incontinence or an indwelling urinary catheter and those who are recovering from rectal or genital surgery or childbirth. Using antiseptic cleanser on the meatus may cause irritation and increase the risk of infection. The patient may perform perineal care but should do so more frequently than once a day. Clean, not sterile, gloves must be worn during perineal care.

To decrease the risk of infection in a patient with an indwelling urinary catheter, what should the nurse do? A. Use antiseptic cleanser on the urinary meatus. B. Provide perineal care more frequently. C. Use sterile gloves when providing perineal care. D. Allow the patient to perform perineal care once a day.

C. Lying flat with a pillow under the knees The patient should lie flat on the back with a small pillow under the knees to move secretions from the anterior upper lobes. Sitting upright in a chair facilitates drainage of left and right posterior apical bronchi. Having the patient lie on the right side in the Trendelenburg position may facilitate moving secretions from both the left upper lobe lingular bronchi and the left lower lobe lateral bronchi. Lying on the left side in the Trendelenburg position facilitates secretions from the right middle lobe bronchus but not the left side.

To move secretions from the right and left anterior upper lobe bronchi, the patient should be in which position? A. Sitting upright B. Lying on the right side C. Lying flat with a pillow under the knees D. Lying on the left side in the Trendelenburg position

A. Cleanse from the area of least contamination to the area of most contamination. Nurses must understand that the direction of cleansing should be from the area of least contamination to the area of most contamination to prevent microorganisms from entering the urethra. Cleansing from the rectum to the urethra increases the risk of contamination. Tension on a catheter could result in accidental removal and pressure on the bladder sphincter. Cotton balls may also be used for cleansing patients with indwelling catheters.

To prevent the risk of contamination during perineal care of a female or male patient, what should the nurse do? A. Cleanse from the area of least contamination to the area of most contamination. B. Cleanse from rectum toward the urethra for the least amount of contamination. C. Apply tension on the urinary catheter to cleanse the most proximal portion of it. D. Use only a washcloth for cleansing patients with indwelling catheters.

A. Use the probe to check own pulse. Sensitivity can be verified by checking own pulse. Hot water should never be used to clean a probe, and many manufacturers do not recommend bleach. The manufacturer's guidelines should be checked before cleaning. Changing probes may ultimately be necessary, but it would not be the first step in troubleshooting this situation. Pressing harder with the probe will not help and may, in fact, obliterate any sounds that are present.

Vascular sounds are not audible with the Doppler probe over the site where the brachial artery is palpable. What is the best way to assess the sensitivity of the instrument? A. Use the probe to check own pulse. B. Use bleach and hot water to clean the probe. C. Change probes. D. Press harder with the probe.

A. Asking the parents for the child's usual weight Knowing the child's usual weight, as well as the current weight, can provide helpful information about fluid status. Fever may lead to dehydration, but the presence of a fever does not indicate anything about current hydration status. A change in reflexes is not associated with a child's hydration status. Breath sounds do not reflect hydration status in children, except in cases of significant fluid overload, usually from IV fluids.

What action is appropriate when evaluating hydration status in an infant? A. Asking the parents for the child's usual weight B. Taking a rectal temperature C. Checking the infant's reflexes D. Listening to breath sounds bilaterally

D. Continue to offer the urinal on a regular basis. Older male patients may require urinal use more frequently to avoid urinary incontinence. Fluid intake should not be decreased unless the patient is on fluid restrictions. A patient who has voided three times during one shift has an adequate fluid intake, and it does not need to be increased. This voiding pattern is normal for an older male patient, so notifying the practitioner is not warranted.

What action should the nurse consider for an 81-year-old male patient who has voided three times during one shift? A. Decrease the patient's fluid intake. B. Increase the patient's fluid intake. C. Notify the practitioner. D. Continue to offer the urinal on a regular basis.

A. Ambulation to the toilet or placement on a bedpan Removal of the impaction may stimulate the defecation reflex; therefore, the patient should be helped onto a bedpan or to the toilet. Ambulation may stimulate further bowel evacuation; therefore, the patient should sit on the toilet to complete the bowel movement before ambulating. Placing the patient in a chair or comfortable position in bed after the removal procedure is important, but first the patient should be set up to complete the bowel movement.

What assistance should the nurse provide for the patient after removal of a fecal impaction? A. Ambulation to the toilet or placement on a bedpan B. Ambulation for further bowel stimulation C. Seating the patient in a bedside chair D. Positioning the patient comfortably in bed

B. "You need to remain still for the procedure." The patient should remain still throughout the procedure. Movement may result in inaccurate results. Inform the patient that some pressure may be felt as the probe is applied to the skin. An ultrasonic transmission gel enhances the transmission of sound. Using a recommended gel by the manufacturer will improve the accuracy of the test and protect the crystals in the probe.

What instruction should be given the patient prior to using Doppler ultrasound to obtain peripheral pulses? A. "There is no pressure applied to the site when using the probe." B. "You need to remain still for the procedure." C. "You will be expected to move during the procedure." D. "Gel will be used to reduce transmission of the sound."

A. "You need to remain still for the procedure." The patient should remain still throughout the procedure. Movement may result in inaccurate results. Inform the patient that some pressure may be felt as the probe is applied to the skin. An ultrasonic transmission gel is used to enhance the transmission of sound.

What instruction should the nurse give the patient prior to using a Doppler ultrasound device? A. "You need to remain still for the procedure." B. "There is no pressure applied to the site when using the probe." C. "You will be expected to move during the procedure." D. "Gel will be used to reduce transmission of the sound."

B. The cuff is too small for the extremity. A cuff that is too small for a large arm will cause too little compression of the artery at the suitable pressure level. The corrective action is to reapply a larger cuff to the upper arm. Resistance to pressure generated by the heart is a result of an elevated extremity and will cause a false-low reading. A cuff that is not snugly applied can result in a false-high reading due to uneven and slow inflation, resulting in varying tissue compression.

What is a possible explanation for a false-high reading obtained from an obese patient's arm? A. The cuff is too large for the extremity. B. The cuff is too small for the extremity. C. Resistance to pressure is generated by the heart. D. The cuff is too snug for the extremity.

A. Use one or more senses to create an image of a desired result. To help decrease pain perception, the nurse should instruct the patient to use one or more senses to create positive images. The process of concentrating on positive images causes the muscles to relax, which helps decrease pain, thereby decreasing the amount of medication needed to control pain. Having a patient write down his or her feelings about the illness is not part of guided imagery; it is a means of reflection.

What is a primary goal as the nurse leads a patient through a guided imagery exercise? A. Use one or more senses to create an image of a desired result. B. Concentrate to increase muscle tension. C. Require additional medication to control pain. D. Have the patient write down his or her feelings about the illness.

D. Excess pressure on the probe. A potential cause for no Doppler signal is excess pressure on the probe, which causes occlusion of the vessel. Other causes include blood flow at a speed less than the Doppler instrument can detect, low volume on the device, insufficient quantity of gel, and damaged equipment or a dead battery.

What is an explanation for lack of a Doppler signal even though blood flow is present? A. No pressure on the probe. B. Excess quantity of gel. C. Speed of blood flow is greater than the Doppler can detect. D. Excess pressure on the probe.

A. They may be controlled by increasing time intervals between doses. Adverse effects of analgesics may be controlled by increasing time intervals between doses, by reducing—not increasing—the dose, or by administering other appropriate medications, such as a stimulant laxative for opioid-induced constipation. Adverse effects of analgesics may include respiratory depression, sedation, constipation, and urine retention.

What is important for the nurse to keep in mind when assessing a patient for analgesic adverse effects? A. They may be controlled by increasing time intervals between doses. B. They are limited to respiratory depression. C. They may be controlled by increasing the dose. D. They may be controlled by limiting stimulant laxatives.

A. Use the OUCHER Pain Scale or Wong-Baker FACES Pain Rating Scale. A child with verbal skills can rate his or her level of pain on the OUCHER Pain Scale or the Wong-Baker FACES Pain Rating Scale. Only one pain-intensity tool should be used consistently with the patient. A 4-year-old child does not have the cognitive ability to use a 0-to-10 pain scale. A child's nonverbal response and his or her own assessment on a pain scale assist the nurse in evaluating the child's pain. These responses are adequate for assessment; therefore, prolonging pain relief and waiting for the parents are not necessary.

What is the appropriate way for the nurse to assess a 4-year-old child for pain? A. Use the OUCHER Pain Scale or Wong-Baker FACES Pain Rating Scale. B. Ask the child to rate his or her pain on a scale of 0 to 10. C. Wait until the parents are present because the child is unable to assist in pain self-assessment. D. Use the OUCHER Pain Scale if the parents are present and the Wong-Baker FACES Pain Rating Scale if the parents are not present.

C. Use the technique in combination with pharmacologic interventions. Nonpharmacologic interventions such as guided imagery should be used in combination with pharmacologic interventions, not in place of them. Guided imagery can help control pain at any pain level and in patients of any age.

What is the appropriate way to use guided imagery with a patient? A. Use the technique in patients who rate their pain level below 2 on a scale of 1 to 10. B. Use the technique in place of pharmacologic interventions. C. Use the technique in combination with pharmacologic interventions. D. Use the technique in patients younger than 60 years of age.

A. Apical pulse for a full minute For children younger than 2 years of age, an apical pulse provides the most reliable HR assessment; because of possible irregularities in rhythm, the HR should be counted for a full minute.

What is the correct method of assessing the HR of a child younger than 2 years of age? A. Apical pulse for a full minute B. Brachial pulse for 15 seconds and multiply by 4 C. Radial pulse for 60 seconds D. Carotid pulse for 30 seconds and multiply by 2

D. Remove the gel from the patient's skin with a wet towel or tissue. Removal of the gel from the patient's skin is the first action taken by the nurse at the end of the procedure. The probe should be disinfected after each patient use, but not before removal of the gel from the patient's skin. Discarding supplies, removing gloves, and performing hand hygiene are steps taken after patient contact is completed.

What is the first action to take upon completion of the procedure? A. Disinfect the probe. B. Discard supplies and remove gloves. C. Perform hand hygiene. D. Remove the gel from the patient's skin with a wet towel or tissue.

D. Bleeding Bleeding is the most common major complication of anticoagulation therapy. Anticoagulation therapy is contraindicated in patients with active bleeding. Hypertension is not usually an adverse effect of anticoagulation therapy. Nausea, vomiting, and diarrhea are possible adverse effects of warfarin therapy.

What is the most common major complication of anticoagulation therapy? A. Diarrhea B. Hypertension C. Nausea and vomiting D. Bleeding

A. The supine position puts the extremities at the level of the heart, yielding the most accurate pressure measurements. When measuring blood pressure on any extremity, the measurement should be taken at the level of the heart to yield the most accurate results. When the patient lies supine, all extremities are at the level of the heart. Obtaining accurate results is the most important reason for having the patient lie supine. The patient should relax for 5 to 10 minutes before blood pressure is measured. Some patients will get pain relief from the supine position, and the supine position helps stimulate blood flow from the brain to the feet. However, none of these is the most important reason for having the patient lie supine during an ABI test.

What is the most important reason for having the patient lie supine during an ABI test? A. The supine position puts the extremities at the level of the heart, yielding the most accurate pressure measurements. B. The supine position relaxes the patient so that pressure measurements are not artificially elevated. C. Patients who have peripheral artery disease cannot tolerate sitting up for long periods of time. D. The supine position helps stimulate blood flow to the lower extremities, yielding the most accurate pressure measurements.

B. Maintain the feet in dorsiflexion The nurse places the patient's feet in therapeutic boots or splints to maintain the feet in dorsiflexion and prevent plantar flexion contractures. Boots and splints are not applied to prevent pressure ulcers, but if they are too tight or placed incorrectly, pressure ulcers may result. Although the therapeutic boots may promote patient comfort, that is not their purpose, nor are they used to prevent contractures of the knee joints.

What is the purpose of therapeutic boots or splints? A. Promote comfort B. Maintain the feet in dorsiflexion C. Prevent pressure ulcers D. Prevent knee contractures

A. The patient may have a heightened awareness of pain. Redirection of attention alters emotional or cognitive aspects of pain; therefore, when distraction is removed, the pain may take the patient by surprise with a heightened awareness. Total and immediate pain control is not a realistic goal with the use of distraction. Although distraction will decrease pain for a time, it will not eliminate the pain. Pain intensity after distraction is often heightened; therefore, minimal pain intensity is not an expected response.

What may the patient experience after using distraction to divert his or her attention from pain? A. The patient may have a heightened awareness of pain. B. The patient may immediately have the pain under total control. C. The patient may not experience further pain. D. The patient may state that the pain intensity is minimal.

D. 50% Half of the patients with untreated DVT develop PE. When PE is diagnosed, the practitioner should also assess the patient for DVT. Because of the risk of a potentially fatal PE, DVT must be treated.

What percentage of patients with untreated DVT develop PE? A. Less than 30% B. 25% C. 75% D. 50%

B. A combination of pain medication and deep breathing techniques controls pain more effectively. A combination of deep breathing techniques and pain medication helps the patient control pain. The nurse should explain that medication may be needed to reduce pain so the patient can relax, and deep breathing can augment the medication's effects. Deep breathing can be used both preoperatively and postoperatively. Pain medication alone may not always relieve a patient's pain; nonpharmacologic methods such as deep breathing may be needed. Even though deep breathing can help relieve pain, it alone may not completely control postoperative pain.

What should patients understand when learning about pain management? A. Deep breathing is used to control anxiety before surgery only. B. A combination of pain medication and deep breathing techniques controls pain more effectively. C. Pain medication always controls pain. D. Deep breathing techniques control postoperative pain completely.

B. A combination of pain medication and nonpharmacologic aids controls pain more effectively. The nurse should explain that medication may be needed to reduce pain so the patient can relax and that nonpharmacologic aids can augment the medication's effects. Progressive relaxation can be used both preoperatively and postoperatively. A combination of pain medication and nonpharmacologic aids assists patients in controlling pain. Pain medication alone may not control a patient's pain. Although nonpharmacologic therapies may aid in reducing postoperative pain, they may not be able to completely relieve it.

What should patients understand when learning about pain management? A. Progressive relaxation is used to control anxiety before surgery. B. A combination of pain medication and nonpharmacologic aids controls pain more effectively. C. Pain medication always controls pain. D. Nonpharmacologic aids control postoperative pain completely.

B. Older adults may not admit to having pain. Older adults and patients from various cultures may not admit to having pain, or they may use the word pain only for severe pain. In some cultures, expressing pain is unacceptable; the nurse must assess nonverbal and physiologic signs of pain to identify it. Older adults may not use the word pain to describe their pain; they may use words such as ache, sore, or hurt to describe pain.

What should the nurse consider when assessing the pain status of an older adult? A. Older adults are more likely to experience chronic pain. B. Older adults may not admit to having pain. C. Older adults have a lower risk of pain associated with invasive procedures. D. Older adults from various cultures are likely to describe their pain accurately.

A. Reassess the patient's pain status, allowing for sufficient onset of action per medication, route, and the patient's condition. The nurse should evaluate the effectiveness of pain-relieving interventions by asking the patient to verbalize how well the pain has been relieved. The nurse must allow adequate time for the medication to work before assessing the effectiveness of interventions or before the patient participates in ADLs. Many pain medications do not reach full effect in 15 minutes. The schedule for the next pain medication administration cannot be determined without reassessing the patient's pain and consulting the practitioner's orders.

What should the nurse do after administering acetaminophen or oxycodone to a 35-year-old patient for pain? A. Reassess the patient's pain status, allowing for sufficient onset of action per medication, route, and the patient's condition. B. Encourage the patient's participation in ADLs immediately after administering pain medication. C. Reassess pain intensity using the same scale after 15 minutes. D. Readminister the pain medication within 30 minutes.

B. Check the catheter tubing for kinks The nurse should first check the tubing for kinks and observe whether urine is pooling at the tip of the condom. The nurse should notify the practitioner only if the urine output remains low and the urinary drainage system is patent. The nurse should assess the catheter and tubing before pushing large amounts of fluids. Condom catheters are not irrigated.

What should the nurse do before applying a new condom? A. Shave the hair at the base of the penis B. Apply barrier cream C. Cleanse the urethral meatus and penis thoroughly D. Irrigate the catheter tubing

C. Cleanse the urethral meatus and penis thoroughly With each catheter change, the nurse should cleanse the urethral meatus and penis thoroughly and look for signs of skin irritation. When necessary, hair at the base of the penis should be clipped, not shaved. Barrier creams should not be used because they prevent the sheath from adhering to the penile shaft. Condom catheters are not irrigated.

What should the nurse do before applying a new condom? A. Shave the hair at the base of the penis B. Apply barrier cream C. Cleanse the urethral meatus and penis thoroughly D. Irrigate the catheter tubing

B. Perform controlled coughing every hour while awake. Controlled coughing helps to reduce the risk of coughing spasms and clears the airway, which improves lung expansion. Taking quick short breaths does not improve lung expansion. Holding breath is not recommended after IS to improve lung function, and although the patient may need to rest, this would not improve lung expansion.

What should the nurse encourage the patient to do in addition to the IS exercises to improve lung expansion? A. Take quick short breaths. B. Perform controlled coughing every hour while awake. C. Hold their breath. D. Rest for 15 minutes before repeating the IS exercise.

C. Wash from the perineal area toward the rectum. Cleansing downward from the pubic area toward the rectum in one smooth stroke reduces the transfer of microorganisms to the urinary meatus. The direction of cleansing should be from the area of least contamination to the area of most contamination. Wiping from front to back reduces the risk of transmitting fecal organisms to the urinary meatus. Washing from the rectum toward the perineal area or washing the rectum first may transfer microorganisms to the urinary meatus. A circular cleansing motion is used on the penile tip in male patients.

What should the nurse teach an older adult female patient who has been admitted with urosepsis to do? A. Wash forward from the rectum toward the perineal area. B. Wash in a circular motion when cleansing the perineal area. C. Wash from the perineal area toward the rectum. D. Cleanse the rectal area before cleansing the perineal area.

B. How to administer subcutaneous injections The nurse should instruct the patient on how to self-administer a subcutaneous injection because the patient is likely to receive a prescription for LMWH. The nurse must ensure that the patient can obtain the medication and administer it appropriately. Care of a central venous device, home blood pressure monitoring, and blood glucose monitoring are not necessary for DVT management but may be required if the patient has certain comorbidities.

What should the nurse teach an outpatient with DVT? A. How to monitor blood pressure B. How to administer subcutaneous injections C. How to care for a central venous device D. How to monitor his or her blood glucose level

A. To rest between periods of activity, such as deep breathing The patient should be taught to rest between periods of activity to conserve energy and prevent respiratory difficulties. If the patient is not experiencing pain, medication may not be needed. The patient should breathe deeply to prevent the Valsalva response, which can increase intrathoracic pressure and compromise cardiac function. The patient should not continue deep breathing until shortness of breath occurs because the patient could experience respiratory distress that could lead to a medical emergency.

What should the nurse teach the patient? A. To rest between periods of activity, such as deep breathing B. To take pain medication before performing deep breathing even if the patient is not experiencing pain C. To breathe out forcibly while the mouth and nose are firmly closed to stimulate a Valsalva response D. To continue deep breathing until shortness of breath occurs

D. Monitoring the patient's oxygen saturation level and accessory muscle use Assessing for respiratory compromise during the procedure is the most important item among the answer options. A patient may not tolerate the modified Trendelenburg position and may develop respiratory distress. Assessing for anxiety, monitoring for improvement in blood pressure, and knowing the degree of elevation of the lower extremities are all necessary, but airway and breathing take priority.

When a patient is placed in the modified Trendelenburg position, which action is most important for the nurse to perform? A. Evaluating the patient for increased anxiety level B. Monitoring the patient's diastolic blood pressure C. Determining the degree of elevation of the lower extremities for documentation purposes D. Monitoring the patient's oxygen saturation level and accessory muscle use

C. Color of sputum The color of sputum may indicate that the patient has an infection, which may lead to pulmonary complications. The time of day when a patient produces sputum has no relationship to the presence of pulmonary complications, nor does the length of time between periods of coughing and deep breathing. If the patient's lung sounds are clear after coughing, this is a good sign, but it does not necessarily indicate that the patient is experiencing pulmonary complications.

When assessing a patient for the presence of pulmonary complications, which finding or situation should the nurse consider? A. Whether patient's lung sounds are clear after coughing B. Time of day when the patient produces sputum C. Color of sputum D. Length of time between the patient's periods of coughing and deep breathing

C. Auscultate over each quadrant. To auscultate bowel sounds, the nurse should place the diaphragm of the stethoscope lightly over each abdominal quadrant and listen over each one before deciding that bowel sounds are absent. Placing the patient's arms under the head or keeping the patient's knees fully extended may cause the abdominal muscles to tighten. Muscle tightening prevents adequate palpation. Manipulation of body parts, including masses, may increase the patient's pain and anxiety and make it difficult to complete the assessment. Painful areas should be assessed last.

When assessing a patient's abdomen, the nurse should perform what action? A. Palpate masses or organ enlargement deeply and firmly. B. Position the patient in a supine position with the arms behind or over the head. C. Auscultate over each quadrant. D. Assess painful quadrant areas first.

A. The patient's fluid status may be overload. Increased pulsation height may indicate fluid overload or right-side heart failure and is not a normal finding. Normally, veins are flat when the patient is sitting and pulsations become evident as the patient's head is lowered. The patient's fluid status is not normal and the patient is not dry. The change in pulsation does not indicate a variable status. It would be normal for pulsation to decrease as the patient sits up.

When assessing jugular venous pressure, the nurse has the patient assume a supine position and raises the head of the bed slowly. The nurse notices the patient continuing to have pulsation as the head of the bed is raised past 45 degrees. What is the nurse's assessment of the patient's fluid status? A. The patient's fluid status may be overload. B. The patient's fluid status is normal. C. The patient's fluid status is dry. D. The patient's fluid status is variable as indicated by the change of position.

A. Duplex venous ultrasonography Duplex venous ultrasonography, one of the least expensive and least invasive tests, is the most common diagnostic test in the initial workup of a patient suspected of having DVT. MRA or CTV may be used if duplex venous ultrasonography results are negative but the clinical suspicion of DVT remains high. Chest x-ray is not useful in diagnosing DVT.

When caring for a patient suspected of having DVT, the nurse should tell him or her to anticipate which diagnostic test? A. Duplex venous ultrasonography B. MRA C. CTV D. Chest x-ray

D. Slow, deep breaths through the nose Instructing the patient to take slow, deep breaths allows increased lung expansion, thus preventing hyperventilation; breathing through the nose allows the air to be warmed, humidified, and filtered. Taking several shallow breaths does not allow the lungs to expand and increases the patient's risk for developing atelectasis. Breathing through the mouth also does not allow the air taken in to be warmed, filtered, and humidified. Taking rapid breaths does not allow the lungs to expand fully and may increase the risk of respiratory complications.

When explaining how to perform diaphragmatic breathing, what type of breaths should the nurse instruct the patient to take? A. Four rapid breaths through the nose B. Several shallow breaths C. Short, deep breaths through the mouth D. Slow, deep breaths through the nose

C. Place a pillow over the incisional site for splinting The nurse should teach the patient to place a pillow over the incisional area and place the hands over the pillow to splint the incision. Breathing exercises should be repeated three to five times each day rather than just twice. The patient should be instructed to cough fully for two or three consecutive coughs without inhaling between coughs; such consecutive coughs help remove mucus more effectively and completely than one forceful cough. The nurse should instruct the patient to avoid using chest and shoulder muscles while inhaling during diaphragmatic breathing because using these muscles during breathing results in unnecessary energy expenditure and does not promote full lung expansion.

When instructing a patient who has a thoracic or abdominal incision about the performance of postoperative controlled coughing, what should the nurse tell the patient to do? A. Cough two or three times and inhale between each cough B. Repeat the breathing exercises twice each day C. Place a pillow over the incisional site for splinting D. Use the chest and shoulder muscles while inhaling during diaphragmatic breathing

B. Ask the patient to cough Rhonchi, caused by muscular spasm, fluid, or mucus in the larger airways, often clear or lessen by coughing. Repositioning the patient does not clear the large airways. The anterior and posterior chest examination may differ, regardless of findings. Lung auscultation for an adult is best performed using the diaphragm of the stethoscope.

When listening to a patient's posterior chest, the nurse hears loud, coarse rumbling sounds throughout the respiratory cycle. What action would the nurse take next? A. Reposition the patient and listen again B. Ask the patient to cough C. Switch to the bell of the stethoscope D. Confirm findings in the anterior chest

C. "This position will take pressure off your legs and allow you to get more comfortable." The best response is to explain to the patient that the side-lying position will take the weight of the fetus off the vena cava and allow more effective blood return to the heart. The side-lying position will not induce labor. This position may make the patient more comfortable by taking pressure off legs and back, but the best response emphasizes the importance of blood return to the heart.

When nurse places a patient who is 40-wk pregnant with hypotension on her left side, the patient asks why this is done. What is the nurse's best response? A. "This position will allow your baby more space and may induce labor." B. "This will keep you from getting a sore back from lying flat." C. "This position will take pressure off your legs and allow you to get more comfortable." D. "This will take the weight of the baby off the blood vessel that returns blood to your heart."

D. Stop the feeding 30 to 45 minutes before CPT to prevent aspiration. CPT is not contraindicated because a patient is receiving tube feedings; however, tube feedings should be stopped 30 to 45 minutes before CPT to prevent aspiration. Tube feeding residual does not influence the use of physiotherapy. Withholding feedings because of residuals has no impact on this procedure.

When performing CPT on a patient receiving a continuous feeding via a nasogastric tube, the nurse should perform which action? A. Ensure that feedings are uninterrupted during physiotherapy. B. Withhold therapy if any tube feeding residual is present. C. Not perform CPT because it is contraindicated in patients receiving a tube feeding. D. Stop the feeding 30 to 45 minutes before CPT to prevent aspiration.

A. Place a small pillow under the patient's abdomen below the level of the diaphragm. A small pillow under the patient's abdomen decreases lumbar vertebrae hyperextension and strain on the lower back. The pillow also helps improve breathing by reducing mattress pressure on the diaphragm. Placing the arms over the patient's head or bending the patient's legs into a frog position does not decrease lumbar vertebrae hyperextension or strain on the lower back. A pillow under the shoulder blades does not decrease strain on the lower back.

When positioning a patient in the prone position to decrease lumbar vertebrae hyperextension and strain on the patient's lower back, the nurse should take which action? A. Place a small pillow under the patient's abdomen below the level of the diaphragm. B. Bend the patient's legs into a frog position. C. Place the patient's arms over the head with the elbows bent. D. Place a small pillow under the patient's shoulders between the shoulder blades.

D. Every 2 hours Turning every 2 hours while awake is standard instruction to decrease the risk of vascular complications and allows the patient an opportunity to rest. The plan may be individualized for the patient; some patients may need more frequent turning based on their diagnosis and history. Turning only four times per day increases the chance of a vascular complication. Waiting to turn until the patient feels uncomfortable risks a pressure ulcer; discomfort may be an early sign of skin breakdown. Because of postoperative pain, the patient may not want to turn at all, but refraining from turning increases the risk of vascular complications.

When providing postoperative teaching to a patient, the nurse should tell the patient to turn and change position how often? A. Only if pain free B. Four times per day C. When feeling uncomfortable D. Every 2 hours

C. At the end of exhalation The nurse should insert the balloon end of the fecal containment device at the end of exhalation when the rectal sphincter is most relaxed. The nurse should not insert it with the patient taking a deep breath, bearing down, or holding his or her breath because the rectal sphincter is not relaxed in these situations; thus, insertion would be difficult and might cause damage to the rectal mucosa.

When should the nurse insert the balloon end of the indwelling fecal containment device? A. At the end of deep inspiration B. With the patient bearing down C. At the end of exhalation D. With the patient holding his or her breath

B. To increase oxygenation and reduce anxiety Slow, deep breaths can increase oxygenation, reduce anxiety, and prevent shortness of breath associated with relaxation. Breaths should be diaphragmatic and deep to prevent hyperventilation. Relaxation reduces anxiety and decreases the pulse, respiratory rate, and blood pressure. Muscles should be tightened during inhalation and relaxed during exhalation. Stimulating the sense of smell may not produce the feeling of relaxation.

When teaching a patient about progressive relaxation, the nurse should give which reason for taking several slow, deep breaths? A. To stimulate the sense of smell to aid relaxation B. To increase oxygenation and reduce anxiety C. To increase the respiratory rate and oxygenation D. To relax muscles during inhalation and tighten muscles during exhalation

A. Upper left portion of the heart The base of the heart is in the upper left portion of the heart; the bottom tip of the heart is the apex. The student nurse must know this because visualization improves the ability to assess findings accurately and helps to determine the possible source of abnormalities.

When teaching a student nurse how to auscultate the heart, the nurse correctly explains that the base of the heart is located in which area? A. Upper left portion of the heart B. Bottom tip of the heart C. Middle range of the heart D. Proximal side of the heart

C. Slowly through pursed lips Exhaling slowly through pursed lips permits optimal exchange of oxygen and carbon dioxide. Exhaling quickly into a paper bag may cause dizziness. Exhaling while bearing down is not indicated for breathing exercises. Exhaling through the nose is not indicated because it does not optimize gas exchange.

When teaching breathing techniques, the nurse should instruct the patient to exhale how? A. While bearing down B. Quickly into a paper bag C. Slowly through pursed lips D. Through the nose

A. Place a small pillow under the shoulder of the affected side. Placing a small pillow under the affected side decreases the risk of pain, joint contractures, and subluxation. Pillows may be used between the extremities for comfort. The affected arm should be placed away from the body with the elbow extended and the palm up. The family should be encouraged to turn and position the patient diligently as a way to avoid contractures.

When teaching family members to position a hemiplegic patient in a supine position, the nurse should emphasize which teaching point? A. Place a small pillow under the shoulder of the affected side. B. Do not place pillows between the extremities. C. Place the affected arm so it lies close to the body. D. Expect contractures to develop in as little as 2 weeks because they cannot be avoided.

B. Explore alternative nonpharmacologic techniques. Because individuals respond differently to nonpharmacologic techniques, finding those that work best for a particular patient takes time. The nurse should not insist that the patient use a technique that he or she does not find effective. The nurse should not assume that the patient is pain free just because he or she states that a nonpharmacologic approach is not effective, nor should the nurse scold the patient about his or her preference.

When the nurse introduces guided imagery to a patient, the patient laughs and calls the technique silly. Which intervention should the nurse use? A. Remind the patient that this technique has been proven to be successful. B. Explore alternative nonpharmacologic techniques. C. Firmly explain to the patient that laughing defeats the purpose of the exercise. D. Recognize that the patient is no longer in pain.

C. Obesity Because of the mass and body composition of obese patients, the supine position may cause ventilatory impairment due to pressure on the diaphragm along with compression on the aorta and inferior vena cava. Arthritis, diabetes, and dementia do not directly affect the ventilation status of a patient in the supine position.

When the nurse places the patient in a supine position in preparation for the modified Trendelenburg position, the patient's oxygen saturation drops. Which pre-existing condition would most directly contribute to this condition? A. Arthritis B. Diabetes C. Obesity D. Dementia

A. Assist by pushing down with his or her feet on the bed surface. When the patient is able to assist, he or she should push down with the heels and elevate the trunk during the move. Lifting the feet increases the workload during a move. The patient should be instructed to breathe out, not take a large breath in, during the move, thereby avoiding the Valsalva maneuver. The patient should lie supine while being moved up in bed.

When the patient is able to assist and two nurses are working together to move him or her up in bed, one nurse should instruct the patient to perform which action? A. Assist by pushing down with his or her feet on the bed surface. B. Lift the feet while being shifted. C. Take a large breath in while being moved. D. Roll to a side-lying position immediately before being moved.

A. The patient is positioned with pillows under the legs. Before applying stockings, the patient is positioned into a supine position of comfort for ease of application. The patient should be discouraged from crossing the legs or placing pillows under the knees. These practices can promote venous stasis. Before application, the legs can be bathed and thoroughly dried. Care should be taken to avoid wrinkles, as these can impede circulation and cause constriction.

Which action by the caregiver indicates that more education is required for a patient wearing antiembolic stockings? A. The patient is positioned with pillows under the legs. B. The caregiver bathes the legs and dries them thoroughly before applying the stockings. C. The caregiver smooths the wrinkles during application of the stockings. D. Stockings are applied with the patient in the supine position.

C. Evaluating the patient's medication history The patient's medication history should be evaluated. Certain medications can predispose a patient to orthostatic hypotension and produce unreliable results regarding fluid status. IV access is not necessary to obtain orthostatic vital signs. The patient needs to lie in a supine position for 5 to 10 minutes before the initial measurement. Checking orthostatic vital signs is contraindicated in patients with severe alterations in mental status.

Which action should be taken before checking a patient for orthostatic vital sign changes? A. Instructing the patient to lie supine for 1 minute before the initial measurements B. Enlisting help if the patient has a severe alteration in mental status C. Evaluating the patient's medication history D. Initiating an IV line

C. Supporting the patient's feet with a footboard Supporting the patient's feet with a footboard will support the position without expending the patient's energy. The knee gatch should be used only for a limited time because it creates pressure on the popliteal vessels. Posey vests are restraints and should not be used. The patient must expend energy to use side rails for support, and a dyspneic patient has no energy to spare.

Which intervention helps keep a patient in the high Fowler position? A. Maintaining constant use of the knee gatch B. Securing a comfortable Posey vest C. Supporting the patient's feet with a footboard D. Raising the side rails so the patient can reach them

C. Recording ice chips as 50% of measured volume Liquids with meals, gelatin, custards, ice cream, ice pops, sherbets, and ice chips count as fluid intake. Ice chips are recorded as 50% of measured volume. Patients and families should be instructed to call the nurse to empty the contents of urinals, urine hats, or commodes each time they are used. Chest tube drainage systems are not emptied and are replaced only when full. Liquid medicines such as antacids are counted as fluid intake, as are fluids taken with medications.

Which action would be appropriate when measuring I&O? A. Emptying the chest tube drainage every 2 hours B. Checking urinary output every 24 hours C. Recording ice chips as 50% of measured volume D. Subtracting liquid medications from the total intake

B. A warm, red, swollen lower right extremity A warm, red, swollen lower extremity is highly suspicious for DVT. Fevers associated with DVT are usually low grade, and a fever greater than 38.3°C (101°F) is most likely related to infection. A bulging calf vein is more suggestive of a varicose vein or a superficial thrombophlebitis. PE may be associated with tachycardia, but bradycardia is not a common sign of DVT or PE.

Which assessment finding should make the nurse suspect that a patient may have DVT? A. A fever of 39.4°C (103°F) B. A warm, red, swollen lower right extremity C. A bulging vein in the posterior calf D. Bradycardia with an apical pulse rate of 58 bpm

A. Cushing disease In patients with Cushing disease, corticosteroids can cause sodium and water retention, with potassium excretion. Patients with Addison disease have a deficiency of corticosteroids that causes sodium and water excretion. In diabetic ketoacidosis, osmotic diuresis from increased blood glucose levels causes a fluid volume deficit. A prolonged fever diminishes body fluids by increasing insensible water loss from the lungs through an increased respiratory rate and diaphoresis

Which condition places a patient at risk for increased fluid retention? A. Cushing disease B. Diabetic ketoacidosis C. Febrile conditions D. Addison disease

B. Intake 2000 ml, output 900 ml (500-ml urine, 200-ml emesis, 200-ml liquid feces) A urine output of less than 700 ml in 24 hours is less than the 30 ml/hour, which is the minimum required to indicate that the perfusion of the kidneys is adequate. In the remaining answers, the oral intake and urine output are adequate and appropriately balanced.

Which daily I&O total should the nurse report to the practitioner immediately? A. Intake 1500 ml, output 1100 ml (800-ml urine, 100-ml wound drainage, 200-ml liquid feces) B. Intake 2000 ml, output 900 ml (500-ml urine, 200-ml emesis, 200-ml liquid feces) C. Intake 2500 ml, output 2300 ml (1550-ml urine, 500-ml emesis, 250-ml chest tube drainage) D. Intake 3000 ml, output 2600 ml (2600-ml urine)

C. Engage the patient in conversation and encourage the participation of family members and visitors. The nurse and visitors can help direct attention away from a patient's mild to moderate pain. Conversation is an effective distraction technique; family members should be encouraged to participate, not to remain silent. The patient should be allowed to select the music of his or her choice; jazz music may not be appropriate for a particular patient.

Which distraction technique is an appropriate nonpharmacologic intervention for a patient with moderate pain? A. Ask family members to remain silent during the procedure. B. Ensure no conversation takes place so patient can enjoy the quiet. C. Engage the patient in conversation and encourage the participation of family members and visitors. D. Use jazz music to distract the patient.

A. Purposeful rounds by nursing staff Purposeful rounds by nursing staff that address patient needs, such as toileting, pain, and positioning, can greatly reduce patient falls. Staff must understand that the use of raised side rails should be patient-oriented and reviewed regularly. Greater injury can result from falling while climbing over a side rail. Reducing noise on the unit addresses patient comfort and sleep needs, but is not a factor in patient falls. Placing a patient closer to the nursing station may be effective if the patient requires increased visual monitoring.

Which evidence-based intervention is effective in reducing falls in a nursing unit? A. Purposeful rounds by nursing staff B. Reduction of noise C. Place patient at risk for falls closer to nursing station D. Use of raised side rails

A. Vascular sounds over the epigastric region If vascular sounds over the epigastric region (an aortic bruit) are auscultated, the nurse should stop the assessment and notify the practitioner immediately. An aortic bruit may indicate the presence of an aneurysm. The nurse should not percuss or palpate an area where a suspected bruit is heard. Faint bowel sounds are expected in a postoperative patient. Abdominal organs are more easily palpated in older adults. The most common mass palpated in children is feces; an immediate call to the practitioner is not warranted.

Which finding would necessitate immediate notification of the practitioner? A. Vascular sounds over the epigastric region B. Faint hypoactive bowel sounds in a patient after surgery C. An easily palpable liver in a 70-year-old woman D. A hard mass in the right lower quadrant of a child's abdomen

A. Assume an upright position in bed or on a chair. An upright position promotes optimal lung expansion. The patient should inhale slowly and deeply for maximum lung expansion with minimal risk of alveolar collapse. The patient should exhale normally. The patient performing IS should hold his or her breath for at least 5 seconds; holding a breath for 15 seconds is unrealistic.

Which information should the nurse tell a patient who is learning to use IS? A. Assume an upright position in bed or on a chair. B. Inhale rapidly. C. Exhale quickly. D. Hold your breath for 15 seconds.

C. Placing a pillow under the semiflexed upper leg level with the hip from the groin to the foot Pillows and supports that decrease the pressure on bony prominences decrease the likelihood of skin breakdown; raising the patient's heels off the mattress reduces pressure on the heels. The patient should be turned more frequently than every 8 hours. The patient's skin should be checked every time repositioning occurs. The patient should change position often, not remain in the supine position.

Which intervention decreases the likelihood of a patient developing skin breakdown or pressure ulcers when turned to the side? A. Turning the patient every 8 hours B. Checking the patient's skin once each shift for signs of breakdown C. Placing a pillow under the semiflexed upper leg level with the hip from the groin to the foot D. Placing the patient in the supine position for the duration of the shift

A. Allowing the patient to maintain the position of comfort The patient will assume a position of comfort naturally to ease respirations. For many patients, the orthopnea (tripod) position is the most comfortable. The patient should not be asked to sit up straight because this may make breathing more difficult. Many patients with dyspnea find that dangling their legs is more comfortable. The over-bed table should be raised to a level that allows the patient to lean over it for support.

Which intervention is appropriate for a patient with COPD who is found in a tripod position? A. Allowing the patient to maintain the position of comfort B. Encouraging the patient to sit up straight C. Not allowing the patient's feet to dangle D. Lowering the over-bed table to knee level

B. Administer an analgesic before implementing a nonpharmacologic technique such as distraction. Nonpharmacologic techniques are used in pain control and can help diminish the physical effects of pain, alter a patient's perception of pain, and provide a patient with a greater sense of control. Administering an analgesic before implementing a nonpharmacologic technique can help the patient gain a level of comfort to participate in the technique. Administering an analgesic after using nonpharmacologic techniques or not administering one at all may not help the patient control pain. Because nonpharmacologic techniques can help decrease pain, the patient may experience a resulting decrease in anxiety.

Which intervention is appropriate? A. When using a nonpharmacologic technique such as distraction, do not administer a pain medication. B. Administer an analgesic before implementing a nonpharmacologic technique such as distraction. C. Administer an analgesic 1 hour after using distraction. D. Use nonpharmacologic techniques such as distraction to relieve anxiety, not to control pain.

A. Reposition the patient in the 30-degree lateral position. Patients at risk for the development of pressure ulcers should be positioned at 30 degrees in the lateral position. Supine positioning may increase the development of pressure ulcers. Log rolling is appropriate for patients who have undergone spinal surgery. Skin should be assessed every time the patient is repositioned.

Which intervention should be incorporated into the plan of care for a patient at risk for pressure ulcer development? A. Reposition the patient in the 30-degree lateral position. B. Maintain the patient in the supine position. C. Reposition the patient using the log-rolling technique. D. Assess the patient for skin breakdown every 24 hours.

A. Arterial sounds are loud and pulsatile. Arterial sounds are loud, pulsatile, pumping sounds that are repeated with each cardiac cycle. Upon expiration, venous sounds are high-pitched and resemble the sound of rushing wind.

Which is a characteristic of arterial sounds? A. Arterial sounds are loud and pulsatile. B. Arterial sounds are muffled and pulsatile. C. Arterial sounds resemble the sound of rushing wind. D. Arterial sounds are high-pitched.

C. Mucosal dryness Because most oxygen delivery systems do not routinely use humidification, patients on continuous oxygen are at risk of mucosal dryness. Aspiration, feelings of suffocation, and feeling hot are potential complications of oxygen mask use but are not usually associated with the use of a nasal cannula.

Which is a potential complication of oxygen therapy via nasal cannula for patients? A. A cold sensation B. Feelings of suffocation C. Mucosal dryness D. Aspiration

D. First sound heard after slow deflation of the cuff begins Korotkoff phase I is the first sound heard after deflation of the cuff and reflects the systolic pressure. This sound is clear, repetitive, and tapping in nature. It often coincides with the reappearance of a palpable pulse.

Which is correct regarding Korotkoff phase 1 sounds? A. Last sound heard after deflation of the cuff begins B. Reflect the diastolic pressure C. Sound muffled D. First sound heard after slow deflation of the cuff begins

C. The length of the cuff bladder should be 80% of arm circumference. An appropriate-size blood pressure cuff will result in the most accurate readings. The length of the blood pressure cuff bladder should be 80% of arm circumference, and the width of the bladder should be at least 40% of arm circumference.

Which is correct regarding size of a pediatric blood pressure cuff? A. The length of the cuff bladder should be 40% of arm circumference. B. The width of the bladder should be at least 80% of arm circumference. C. The length of the cuff bladder should be 80% of arm circumference. D. The width of the bladder should be at least 20% of arm circumference.

B. Arteries may be stiffer. Arterial stiffening is a normal result of aging. Arteries lose elasticity with aging. A higher ankle-brachial index is an expected finding due to arterial stiffening.

Which is true regarding the vascularity of an aging patient? A. Arteries have more elasticity. B. Arteries may be stiffer. C. A lower ankle-brachial index is to be expected. D. Stiffening of arteries is not part of the normal aging process.

B. Effleurage, petrissage, and friction Effleurage (massaging upward and outward from the vertebral column and back again), petrissage (kneading the muscles), and friction (use of strong, circular strokes) are all effective massage strokes. Manipulation of deep muscles should be avoided during massage, although kneading of muscles during petrissage promotes muscle relaxation. Muscle extension is not a component of massage.

Which massage strokes are appropriate for a postoperative patient? A. Effleurage, petrissage, and manipulation B. Effleurage, petrissage, and friction C. Kneading, manipulation, and effleurage D. Stroking, friction, and muscle extension

A. Calculation of calories consumed at each meal Calculation of calories consumed requires assessment by a registered dietitian. Nurses may assist the registered dietitian by recording meal intake to determine if additional nutrition support is needed; by identifying recent weight loss and loss of appetite, which are specific and sensitive indicators of nutritional risk; and by asking about medication and herbal supplement use to evaluate possible interactions that could impact appetite.

Which nutritional assessment should be performed by a registered dietitian? A. Calculation of calories consumed at each meal B. Meal intake or appetite C. Weight gain or loss D. Medication and herbal supplement use

C. Presence of IV therapy The six variables included in the MFS include falls within the last 3 months, gait or transfer problems, IV line for therapy, altered mental status, secondary diagnosis, and use of an ambulatory aid. Use of benzodiazepines, use of restraints, and assessment of toileting needs are not part of the MFS, but are important components of addressing fall risk.

Which of the following assessment items is included in the MFS? A. Use of benzodiazepines B. Use of restraints C. Presence of IV therapy D. Toileting needs

D. Frequently monitoring the patient's heart rate Because vagal stimulation, leading to decreased heart rate and arrhythmias, may occur during removal of the fecal impaction, the nurse should monitor the patient's heart rate frequently. The procedure should be completed in a timely manner but should not be hurried. The nurse should be gentle to decrease the amount of trauma and vagal stimulation and remove small pieces of the impaction at a time to decrease the patient's discomfort and trauma to the rectum. The nurse's gloved fingers should be lubricated to ease the extraction; however, the priority is to monitor the patient's heart rate.

Which of the following is a priority nursing intervention during digital removal of a fecal impaction? A. Periodically relubricating the fingers removing the impaction B. Quickly removing the maximum amount of fecal impaction C. Removing large portions of stool at a time D. Frequently monitoring the patient's heart rate

A. Patients taking beta blockers may not have significant changes in heart rate. Patients who are taking medications that block beta receptors are unlikely to be able to produce significant changes in heart rate. The patient's arm should be supported at the level of the heart to prevent inaccurate measurements. High Fowler position is the alternative to standing for those patients who cannot stand, but the results are less credible. A systolic blood pressure decrease of 20 mm Hg or more is often considered a positive finding.

Which of the following is important to remember when measuring orthostatic vital signs? A. Patients taking beta blockers may not have significant changes in heart rate. B. A systolic blood pressure increase of 30 mm Hg or greater is indicative of a positive finding. C. The patient's arm should rest at his or her side when the sitting and standing values are being measured. D. If a patient cannot stand, readings taken in the high Fowler position will be equally accurate.

D. An older adult patient in traction Immobility risk factors include paralysis, impaired mobility (e.g., traction), impaired circulation, and advanced age. The older adult patient in traction is at greatest risk for complications of immobility because of age and the traction. Although young age is sometimes a risk factor for skin breakdown, a child admitted for a transient illness is not at greatest risk. The patient with transient chest pain is not at greatest risk for immobility complications because the patient is mobile. The patient who has suffered a stroke is not at greatest risk for these complications because the patient is mobile with a walker.

Which patient has the greatest risk of immobility complications? A. A young child with an asthma exacerbation B. A mobile patient with transient chest pain C. A patient who has suffered a stroke and must walk with a walker D. An older adult patient in traction

D. "Concentrate on taking slow rhythmic breaths." Concentrating on slow rhythmic breathing promotes relaxation and reduces the patient's ability to concentrate on pain. Taking shallow rapid breaths, holding one's breath for as long as possible then taking a deep breath, or taking two long breaths followed by two short breaths would not promote relaxation and may make it difficult for the patient to be distracted from pain.

Which patient instruction is appropriate when using distraction as a comfort technique? A. "Take two long breaths followed by two quick, short breaths and repeat this for 10 minutes." B. "Take shallow, rapid breaths." C. "Hold your breath for as long as possible and then take a deep breath." D. "Concentrate on taking slow rhythmic breaths."

D. 74-year-old patient with gastroenteritis Older adults are at greater risk for fluid imbalance from vomiting and diarrhea. Postoperative patients tolerate nothing-by-mouth status well because of fluids administered in the operating room. Fever can lead to fluid imbalance but is well tolerated in younger adults. The chest tube output must be closely monitored, but insertion of the tube does not lead to fluid imbalance directly.

Which patient is at greatest risk for fluid imbalance? A. 27-year-old patient with a chest tube B. 35-year-old postoperative patient receiving nothing by mouth C. 58-year-old patient with a 3-day history of fever D. 74-year-old patient with gastroenteritis

A. A frail older adult patient who is recovering from an embolic stroke and has developed perianal skin breakdown The presence of perianal skin breakdown is an appropriate indication for using a fecal containment device. Contraindications for the use of indwelling fecal containment devices include presence of anal canal strictures, recent rectal surgery, rectal tumors, severe hemorrhoids, a localized inflammatory process or disease, or an incompetent rectal sphincter.

Which patient with acute fecal incontinence with diarrhea is a good candidate for the use of an indwelling fecal containment device? A. A frail older adult patient who is recovering from an embolic stroke and has developed perianal skin breakdown B. A middle-aged patient who is recovering from complications after surgery to remove a malignant rectal tumor C. An older adult patient who has had multiple hospitalizations this year for rectal bleeding associated with hemorrhoids D. A middle-aged patient with a history of bulimia who is awaiting further evaluation of anal canal stricture

C. Lying supine with the neck flexed and the chin to the chest Having the neck flexed and the chin to the chest is a position used while moving the patient in bed; it does not help maintain proper body alignment. Lying prone with pillows under the arms and legs, lying on the right side with a pillow between the knees, and lying supine with a small pillow under the head and the legs extended all help maintain proper alignment.

Which position does not help maintain proper body alignment? A. Lying prone with pillows under the arms and legs B. Lying on the right side with a pillow between the knees C. Lying supine with the neck flexed and the chin to the chest D. Lying supine with a small pillow under the head and the legs extended

D. Wrists slightly extended and fingers partially flexed A patient with flaccid hands needs to have his or her hands in a normal resting position with the wrist slightly extended and fingers partially flexed. Having the fingers fully flexed or extended does not maintain normal alignment and may decrease the mobility of the joints. The wrists should be slightly flexed to maintain a more neutral alignment.

Which position should the nurse use for the flaccid hands of a patient in the supported Fowler position? A. Wrists slightly flexed and fingers fully extended B. Wrists slightly flexed and fingers extended C. Wrists slightly extended and fingers fully flexed D. Wrists slightly extended and fingers partially flexed

C. The patient is supine with the head and torso flat and the lower extremities elevated 15.2 to 30.5 cm (6 to 12 in). When positioning a patient in the modified Trendelenburg position, the torso and head are kept flat but the lower extremities are elevated 15.2 to 30.5 cm (6 to 12 in). If the patient is supine and the head is lower than the torso, then the position is referred to as the Trendelenburg position. The lateral decubitus position is a side-lying position, not a supine position like the modified or traditional Trendelenburg. Elevation of both the lower extremities and the head would cause compression of the abdominal organs, which carries the risk of pulmonary compromise.

Which statement best describes the modified Trendelenburg position? A. The patient is in the lateral decubitus position with the head lower than the feet. B. The lower extremities are elevated 30.5 cm (12 in) with the head slightly lower than the torso. C. The patient is supine with the head and torso flat and the lower extremities elevated 15.2 to 30.5 cm (6 to 12 in). D. The head of the bed is elevated 15.2 cm (6 in) and the lower extremities are elevated 30.5 cm (12 in).

C. "I will let my health care personnel know if any of my medications change." The patient's statement of letting health care personnel know if medications change demonstrates an understanding of warfarin therapy. Medications, herbal preparations, over-the-counter medications, or supplements may interfere with warfarin. Patients do not have to avoid foods that contain vitamin K, but they should be eaten in about the same amount every day so the daily dose of warfarin does not require adjustment. Warfarin does not usually cause elevated blood glucose levels. If a dose of warfarin is missed, it should be taken when remembered unless it is about time for the next dose. The dose should never be doubled up the following day.

Which statement by a patient indicates an accurate understanding of warfarin therapy? A. "The most common adverse effect of warfarin is elevated blood sugars." B. "I must avoid any foods that contain vitamin K, such as leafy green vegetables." C. "I will let my health care personnel know if any of my medications change." D. "If I miss a dose of warfarin, I will just make it up the next day."

C. "It's too late to quit smoking; after 20 years, the damage is done." Smoking cessation, even after many years of smoking, lowers the risk of lung cancer. Individuals who stop smoking live longer than those who continue to smoke. The probability of dying from lung cancer declines with further abstinence. Warning signs of cancer include persistent cough, sputum streaked with blood, chest pains, and recurrent attacks of pneumonia or bronchitis. Asbestos exposure increases the risk of lung cancer.

Which statement by a patient who smokes indicates that the patient needs further education regarding smoking cessation? A. "Working around asbestos increases my risk of lung cancer." B. "If I stop smoking today, I can reduce my risk of lung cancer." C. "It's too late to quit smoking; after 20 years, the damage is done." D. "I should call my doctor if I notice a cough that does not go away."

A. "Keep your arms by your side while we are turning you." The patient's arms should be crossed over his or her chest to avoid injury while turning. Placing a pillow between the legs, using a drawsheet to help roll the patient, and placing pillows behind the patient during repositioning maintain proper body alignment.

Which statement by the nurse is not appropriate before logrolling a patient? A. "Keep your arms by your side while we are turning you." B. "We will put a small pillow between your knees before rolling you." C. "After turning you, we will put pillows behind your back for support." D. "We will use the drawsheet to help roll onto your right side."

A. "You can remain still; please do not try to help push up in the bed." he patient should be allowed to assist as much as possible during interventions. He or she should not be cautioned against helping unless doing so would cause complications or difficulties. Obtaining assistance makes repositioning easier. Assessing pain before repositioning allows the nurse to decrease painful movements. The nurse should ensure that tubes and lines are secured while moving the patient.

Which statement by the nurse would not be appropriate before moving a patient up in bed. A. "You can remain still; please do not try to help push up in the bed." B. "I am going to get assistance to help pull you up in the bed." C. "Tell me about your level of pain before we move you up in the bed." D. "I am going to be careful with these tubes and IV lines when moving you."

A. Assess the patient's apical pulse for a full minute. The full-minute assessment of the central pulse provides the most accurate assessment data. The nurse should assess a patient's apical pulse for a full minute when there is a history of cardiovascular disease or arrhythmias. Because the patient has atrial fibrillation, finding an irregular pulse is not surprising, and emergency measures are not required unless the patient is symptomatic.

Which technique is appropriate when the nurse is assessing a clinically stable patient who has a history of cardiovascular disease and chronic atrial fibrillation? A. Assess the patient's apical pulse for a full minute. B. Count the radial pulse and document that it is irregular. C. Call in the rapid response team. D. Call the practitioner immediately.

A. "My mother's pain should be at the level that is comfortable for her." Effectively managing a patient's pain does not mean eliminating pain. Pain management collaboration with the patient and family helps identify an acceptable intensity of pain that allows maximum patient functioning. The level of pain may not always be 0 on a numeric rating scale. Pain medications should be given before the patient reaches a pain level that is beyond acceptable. Withholding pain medication until the pain reaches severe levels does not decrease the likelihood of addiction. Waiting until pain reaches severe levels may increase the medication needed for the patient to reach acceptable pain levels. Older adults may not admit to having pain, so the nurse must assess nonverbal and physiologic signs of pain.

Which statement indicates that the daughter of an 85-year-old patient suffering from cancer pain understands what the nurse taught her about pain control? A. "My mother's pain should be at the level that is comfortable for her." B. "My mother's pain should always be at a 0 on a scale of 1 to 10." C. "Pain medications should be given when the pain reaches severe levels to decrease the likelihood of addiction." D. "When my mother denies having pain, I should believe her and withhold the pain medication."

B. "I am allowed to take my mask off to eat." The patient should remove the mask only to eat, blow the nose, expectorate, or vomit; a nasal cannula may be necessary to maintain oxygenation while eating. There should not be any flammable materials such as cigarettes around supplemental oxygen. The patient should be instructed to let the nurse know if the bag collapses because there will be decreased oxygen delivery if the bag is not inflated.

Which statement indicates that the patient understands how to use the oxygen mask? A. "I should not worry if the bag attached to the mask collapses." B. "I am allowed to take my mask off to eat." C. "I am allowed to have a cigarette if I turn down the oxygen flow." D. "I should never take my mask off, even if I have to vomit."

C. "This device helps decrease the amount of diarrhea." A fecal containment device does not decrease the amount of liquid stool; it only contains the stool. The fecal containment device helps prevent secondary infections and skin breakdown. Preventing stool from coming in contact with the skin helps prevent breakdown and maintain appropriate perineal hygiene.

Which statement would indicate that a family member requires further teaching regarding the purpose of the fecal containment device? A. "This device helps prevent infection." B. "This device helps prevent further skin breakdown." C. "This device helps decrease the amount of diarrhea." D. "This device helps maintain good perineal hygiene."

C. Direct the patient to experience the sensory aspects of a restful place. The nurse should encourage the patient to experience sensory aspects of a restful place, such as a beach. The patient should concentrate on a relaxing image, not work. Heavy perfumes and incenses may be noxious to the patient. Additional conversation may distract the patient during guided imagery.

Which technique is appropriate when directing guided imagery for a patient with postoperative pain? A. Use a variety of perfumes and incenses to stimulate the sense of smell. B. Direct the patient to concentrate on a time when he or she was busy with work activities. C. Direct the patient to experience the sensory aspects of a restful place. D. Encourage family members to distract the patient by engaging in conversation.

D. 7 The Glasgow Coma Scale score is 7. The patient would score 1 point for the eye-opening response, 4 points for the motor response by exhibiting a flexor withdrawal to pain, and 2 points for a verbal response for mumbling incomprehensible sounds.

While the nurse is assessing a patient's neurologic system, the patient does not open his eyes spontaneously when instructed or in response to painful stimuli. The patient exhibits a flexion withdrawal to pain and mumbles incomprehensible sounds. Using the Glasgow Coma Scale, what score would the nurse assign to this patient? A. 9 B. 6 C. 5 D. 7

B. Question the patient about whether she is having her menses. If the patient is currently having her menses, blood may contaminate the stool specimen, and the test should be deferred until menses is complete. If frank blood appears in a stool specimen, an occult test is not indicated. Red meat may cause false-positive results but would not lead to frank blood in the stool. The specimen should not be sent to the laboratory for analysis because of the frank blood.

While attempting to collect a stool specimen for occult testing in an adult female patient, the nurse notices frank blood in the stool. How should the nurse proceed? A. Obtain a stool specimen from the bloody area for confirmation. B. Question the patient about whether she is having her menses. C. Send the entire specimen to the laboratory for analysis. D. Ask the patient if she has consumed red meat in the past few days.

A. The specimen must be collected in a clean, dry container and cannot be contaminated by urine, water, or toilet tissue. An uncontaminated stool specimen is necessary. The specimen should be collected in a clean, dry container, and it must not be contaminated by urine, water, or toilet tissue. A stool specimen is not sterile, so it is not necessary to use a sterile collection technique. The specimen may be obtained by means of a rectal examination, but this is not necessary. Two different areas of a stool should to be used for a slide occult blood measurement because occult blood is not always dispersed evenly throughout stool.

While educating a patient about obtaining a stool specimen for occult blood measurement, the nurse should explain which caution? A. The specimen must be collected in a clean, dry container and cannot be contaminated by urine, water, or toilet tissue. B. One area of the stool specimen must be used for the occult blood measurement. C. The specimen must be collected using sterile technique. D. The specimen must be obtained by means of a rectal examination.

D. Refrain from elevating the lower extremities If the patient complains of pain, the nurse should refrain from elevating the lower extremities, because it may cause further injury. The nurse should explain the procedure as she performs it and stop if the patient complains of pain. It is not necessary to notify the practitioner prior to initiating this intervention. The traditional Trendelenburg position should not be used because it increases the risk for harm to the patient.

While placing a patient with hypotension in modified Trendelenburg position, the patient complains of increased pain. What should the nurse do? A. Explain to the patient that this position is for his/her own good B. Notify the practitioner immediately C. Use the traditional Trendelenburg position instead D. Refrain from elevating the lower extremities

D. Provide comfort by being present and by holding and cuddling the child. The nurse should encourage the family to stay with a child to facilitate learning and to hold and cuddle the child to provide comfort. The threat of medication administration should not be used to coerce the child. Deep, slow breaths should be encouraged.

While the child is learning to perform deep breathing, what should the family do? A. Instruct the child to take shallow, rapid breaths. B. Leave the room to allow the nurse to teach the child. C. Remind the child that if he or she does not perform deep breathing correctly, pain medication may be administered. D. Provide comfort by being present and by holding and cuddling the child.

D. Discontinue the reading. If the patient reports pain, discontinue the blood pressure measurement and assess the pain. Increased pain may indicate worsening ischemia. Although giving morphine may decrease the pain, stopping the stimulus (i.e., deflating the cuff) is the next action. Inflating the cuff more or elevating the extremity may make the pain and tissue ischemia worse.

While undergoing blood pressure measurements to calculate an ABI, the patient reports increased pain. What is the most appropriate action? A. Elevate the extremity. B. Administer 2 mg of morphine. C. Inflate the cuff 20 mm Hg more. D. Discontinue the reading.

A. BMI may be overestimated in bodybuilders and those with ascites. MI alone is not a perfect measure of being overweight or obese. Clinical judgment must be used when evaluating muscular patients (e.g., bodybuilders) and patients with large amounts of edema or ascites because these physiologic states may lead to an overestimation of the degree of body fat. Weight information may be gathered in several ways, including usual body weight, ideal body weight, actual body weight, and BMI; in most cases, a thorough nutritional assessment requires the collection of all of these weight measures. The change in a patient's weight over time is an inexpensive and relatively accurate method of predicting nutritional status but is not related to the accuracy of BMI.

Why is BMI alone not a perfect measure of being overweight or obese? A. BMI may be overestimated in bodybuilders and those with ascites. B. BMI is not usually needed for a thorough nutritional assessment. C. Changes in a patient's weight over time are a relatively inaccurate measure. D. Changes in a patient's weight over time are expensive to measure.

D. Because of the infant's limited neck strength Infants who cannot sit independently need to be treated in a supine position because their ability to hold up the head and maintain a patent airway is compromised by their limited neck strength. The supine position is not related to a decrease in range of motion. Sitting on the lap of a family member may be used to decrease anxiety. A supine position is not used to facilitate visual assessment.

Why should an infant with dyspnea be placed in a supine position? A. Because of the infant's decreased range of motion B. To decrease anxiety C. To facilitate visual assessment D. Because of the infant's limited neck strength

B. Prevent plantar flexion contractures Pillows are used to maintain the feet in dorsiflexion. Maintaining dorsiflexion helps prevent plantar flexion contractures. Pillows do not prevent a patient from changing position. Pillows do not prevent further skin breakdown or deep vein thrombosis.

Why should the nurse should place pillows under the feet of a patient in a semiprone position? A. Prevent further skin breakdown B. Prevent plantar flexion contractures C. Prevent the patient from repositioning himself or herself D. Prevent deep vein thrombosis

D. Turning and repositioning may reduce stimulation of pain and pressure receptors. Turning and repositioning the patient may reduce stimulation of pain and pressure receptors and maximize pain-relieving interventions. Unless the practitioner has ordered specific positions, the patient receiving pain medication may move freely in bed. Repositioning does not alter the pharmacologic absorption of the medication.

efore administering pain medication to a patient, the nurse assists the patient in attaining a comfortable position with normal body alignment. This intervention is important for which reason? A. After medication is administered, the patient needs to remain flat for at least 4 hours. B. Turning and repositioning minimize the response to pain-relieving interventions. C. Repositioning the patient increases the absorption of the medication. D. Turning and repositioning may reduce stimulation of pain and pressure receptors.

A. "When I have visitors, the noise in the room causes my headache to return immediately." The patient experiencing a headache does not describe the level of pain or the location on his head. A pain assessment should include location, duration, and description of the pain. The nurse should ask the patient to describe what aggravates and alleviates the pain. The patient complaining of right knee, lower back, and left arm pain describes the location, type of pain, and level of pain experienced.

he nurse is assessing a patient for pain. Which statement by the patient would prompt the nurse to ask additional questions? A. "When I have visitors, the noise in the room causes my headache to return immediately." B. "I have intermittent, dull, burning pain in my right knee that is a 7 on a scale of 1 through 10." C. "My lower, middle back constantly aches when I lie in this hospital bed and is the worst pain I have ever experienced." D. "When I turn my head to the right, I experience shooting pain down my left arm that takes my breath away."

A. Side-lying The side-lying position provides an older adult patient more comfort and gives the nurse the opportunity to provide perineal care and inspect the surrounding skin. Older adults with limited mobility need assistance with perineal care.

n older adult patient with limited mobility is admitted to the nursing unit. For this patient, which is the most appropriate position for perineal care and inspection of the surrounding skin? A. Side-lying B. Supine C. Semi-Fowler D. Prone

A. It is comfortable for the patient. The oral method is comfortable for the patient. The tympanic measurement provides the most rapid results. Taking an oral temperature measurement should be delayed if the patient recently ingested hot or cold fluids or foods, chewed gum, or smoked. The oral temperature method should not be used with infants; small children; or confused, unconscious, or uncooperative patients.

Which statement is true regarding the oral temperature method? A. It is comfortable for the patient. B. It produces very rapid measurement results. C. It can be used at any time without restrictions. D. It is appropriate for every patient, no matter his or her age.

D. It may be compared with the patient's baseline lower-extremity BP. Ongoing monitoring and care includes establishing a baseline and comparing each new BP reading with previous readings to detect changes. However, measurements should be compared only if taken from the same extremity. Systolic BP in the legs is usually higher than in the brachial artery, not lower. The thigh is the least preferred and most uncomfortable site in children.

Which statement regarding BP measurement of a lower extremity is true? A. It is the preferred method of assessing BP in children. B. It is comparable to an upper-extremity reading. C. It is usually lower than the upper-extremity reading. D. It may be compared with the patient's baseline lower-extremity BP.

A. The same site should be used when repeated measurements are necessary. The same site should be used when repeated measurements are necessary or when temperature measurements are compared over time. The site should be listed with each documented temperature. The safest and most accurate site for the patient should be used.

After a shift change, the incoming nurse takes the patient's temperature. Which statement about the nurse's site choice is correct? A. The same site should be used when repeated measurements are necessary. B. Using the same site is not necessary when comparing temperatures over time. C. Documentation of the site is unnecessary if the same site was used previously. D. The site should be selected based on the ease and convenience for the nurse.

D. Place the call light within the patient's reach on the side rail or pillow. Placing the call light within the patient's reach is an important safety measure. The bed is to be returned to the lowest position for patient safety. Raising the head of the bed when the patient is in a sitting position on the bed and preparing to lie down may decrease the strain on the patient as he or she lies down because the head is elevated. Soiled linen is to be placed immediately into the appropriate laundry container.

After making an unoccupied bed, the health care professional is preparing for the patient's return to bed. Which important safety measure should the health care professional take? A. Leave the bed in a flat position because when the patient returns to lie down he or she first sits on the side of the bed. B. Wait until the patient returns to allow all soiled linen to be placed in the linen bag at one time. C. Leave the bed in a high position to make assessment easy. D. Place the call light within the patient's reach on the side rail or pillow.

D. Assess the environment and remove hazards. Patients and their environments should be accurately considered for fall risk factors and reduce or eliminate hazards. Restraint orders should be a last resort only, and they should not be on an as needed basis. The patient must be evaluated by the practitioner before lorazepam or other benzodiazepines are prescribed because they can cause a paradoxical agitation in older adult patients and are associated with an increased fall risk. An indwelling catheter is not appropriate as there is no indication the patient is not able to void. Additionally, indwelling catheters often induce a feeling of needing to go, causing the patient to try to get out of bed to go to the bathroom.

An 89-year-old patient is admitted with a urinary tract infection. The patient uses a cane but is still unsteady and answers some questions inappropriately. What should be done first? A. Insert an indwelling catheter to reduce the need for ambulating to the bathroom. B. Call the practitioner for a p.r.n. (as needed) order for lorazepam. C. Call the practitioner for a p.r.n. restraint order. D. Assess the environment and remove hazards.

D. Monitor the patient's skin condition under the sensor. During continuous monitoring, the nurse should regularly assess skin integrity underneath the sensor. Older adults require more frequent assessment of skin integrity because of tissue fragility and decreased elasticity. Using alternate sites in older adults is not necessary; more frequent skin assessment is needed. When continuous monitoring is ordered, the sensor may need to be moved to a different location to avoid creating pressure points. Blankets or other opaque coverings may be used to block ambient light from interfering with the sensor.

An older adult patient is diagnosed with shortness of breath. The nurse is continuously monitoring the patient's oxygen saturation using a pulse oximeter with a reusable finger sensor. Which action should the nurse take? A. Seek an alternate site because older adults have a high incidence of peripheral vascular disease. B. Ensure that the sensor is on the same finger for each measurement for consistency. C. Keep blankets off the hand with the sensor. D. Monitor the patient's skin condition under the sensor.

A. Whether direct sunlight is hitting the sensor Direct sunlight or fluorescent lighting should be avoided when using an oximeter. Factors that affect light transmission (e.g., outside light sources or patient motion) also affect the measurement of oxygen saturation. The nurse may need to protect the sensor with an opaque covering or washcloth. None of the other answer choices is related to ambient conditions in the room.

Because the pulse waveform or intensity can be changed by ambient conditions, what should the nurse consider? A. Whether direct sunlight is hitting the sensor B. Whether the noninvasive cuff is inflated C. Whether the patient's apical and peripheral pulses are equal D. Whether a central site should be used

C. The nurse should determine the previous baseline temperature and measurement site from the patient's record. Identifying trends in body temperature can help determine proper treatment. Knowledge of previous methods and results of temperature measurement can help determine trends. Comparing the temperature reading with the patient's previous baseline is done after the temperature assessment. Ensuring that the patient is in a comfortable position and moving clothing or the gown away from the site are part of the procedure.

Before taking the patient's temperature, what information is most important for the nurse to obtain? A. Compare the temperature reading with the patient's previous baseline. B. Confirm that the patient is in a comfortable position. C. The nurse should determine the previous baseline temperature and measurement site from the patient's record. D. Ensure that the patient's clothing or the gown are moved away from the area.

C. Measure the patient's SpO2. Measuring the patient's SpO2 will help to identify whether the patient has a respiratory issue quickly. Assessing the patient's blood gases would provide important information but would take longer to obtain and wastes valuable time. Reviewing the patient's medication list is important to determine whether the patient has received anything to cause a change in condition but this would not be the first thing to do. The patient's family should be notified after the patient is attended to.

During an assessment at a change of shift, the nurse finds the patient restless, irritable, confused, and with a decreased level of consciousness. After having someone notify the practitioner, what is the nurse's next step while checking the patient's vital signs? A. Assess the patient's arterial blood gases. B. Review the patient's recent medication list. C. Measure the patient's SpO2. D. Notify the family that the patient is confused.

D. By applying gentle pressure to seal the ear canal The shape of the temperature probe allows for gentle pressure to be applied to seal the ear canal from ambient air that could alter a reading. Moving the pinna allows maximum exposure of the tympanic membrane. Movement of the pinna should be backward, up, and out for an adult. For a child younger than 3 years of age, the pinna should be pulled down and back. Taking a tympanic temperature in the ear that the patient has been lying on results in a falsely high temperature reading. A temperature that was not obtained using proper technique may be erroneous.

How can the nurse keep ambient air from altering a tympanic temperature measurement? A. By keeping the probe in place until a temperature is displayed B. By moving the pinna up and down until a reading is obtained C. By taking the temperature in the ear on the side on which the patient has been lying D. By applying gentle pressure to seal the ear canal

A. Fold the linen into a bundle or square, hold it away from the body, and place it in the linen bag. Used linen should not be shaken, placed on the floor, or carried across the room because of the risk of disseminating microorganisms into the air or onto clothing. To reduce the risk of cross-infection, the health care professional should take a linen bag to the patient's bedside and carefully place the used linen directly into the bag. The patient should be side-lying and holding onto the bed rail during the bed change and should not hold the sheets.

How should the health care professional remove the soiled linen from the bed? A. Fold the linen into a bundle or square, hold it away from the body, and place it in the linen bag. B. Shake the linen out before putting it in the linen bag. C. Place the linen on the floor to clean up after the bed change is complete. D. Ask the patient to hold it while the bed is changed.

D. Measure the arm circumference. The nurse should measure the arm circumference to ensure that the cuff width is approximately 40% of the arm's circumference and the length is twice the width. Although the cuff should wrap around the arm's diameter at least once, the proper length is twice the width. An oversized cuff width from the antecubital space to the axilla results in falsely low BP readings; an undersized cuff creates falsely high BP readings.

How should the nurse ensure proper BP cuff size for the upper extremity? A. Use the smallest cuff possible. B. Make sure the cuff wraps around the arm just once. C. Make sure the cuff width spreads from the antecubital space to the axilla. D. Measure the arm circumference.

B. The BP will be overestimated. Studies show that using a cuff that is too narrow results in an overestimation of BP, and a cuff that is too wide underestimates BP.

If the nurse uses a leg cuff that is too narrow, how will the BP results be affected? A. The results will be accurate. B. The BP will be overestimated. C. The BP will be underestimated. D. The lower extremity BP will be lower than the brachial artery BP.

B. Using a Doppler ultrasonic stethoscope A Doppler ultrasonic stethoscope augments the sound of the blood flow in the arteries, making hearing easier. Palpation of lower-extremity BP has limited reliability. Noninvasive BP machines have a limited reliability at extremely low BP readings. Using a double stethoscope and verifying heart sounds with a second nurse do not improve the ability to hear Korotkoff sounds.

If unable to palpate an artery because of the patient's low BP, the nurse may obtain a systolic BP by performing which action? A. Changing to a lower-extremity BP assessment B. Using a Doppler ultrasonic stethoscope C. Using a noninvasive BP machine D. Using a double stethoscope to listen for Korotkoff sounds with a second nurse

D. Flat A flat occupied bed makes removing and applying linens easier. When the head of the bed is raised, removing, and applying linens evenly is difficult. Adjusting the bed to the lowest position forces the heath care professional to bend over to make the bed and may cause back strain. Adjusting the bed to the highest position may make it be too high. The health care professional should position the bed in a comfortable working position.

In what position should the bed be placed for making an occupied bed? A. The highest position B. Raised at the head C. The lowest position D. Flat

A. Point the covered probe toward the midpoint between the eyebrow and hairline. For a child younger than 2 years of age, the covered probe should be pointed toward the midpoint between the eyebrow and hairline. The pinna of the ear should be pulled backward, up, and out for an adult. Some manufacturers recommend moving the speculum tip in a figure-eight pattern (not a circular pattern), which allows the sensor to detect maximum tympanic membrane heat radiation.

Which technique should be used when measuring the body temperature of an 18-month-old child via the tympanic membrane? A. Point the covered probe toward the midpoint between the eyebrow and hairline. B. Pull the pinna backward, up, and out to allow unobstructed access to the ear drum. C. Pull the pinna up, forward, and inward to allow unobstructed access to the ear drum. D. Move the thermometer in a circular configuration to detect maximum heat.

C. Pulse pressure The difference between systolic pressure and diastolic pressure is the pulse pressure. Pulsus paradoxus is a decrease in the strength of the pulse during inspiration. Cardiac output is the amount of blood pumped by the heart in 1 minute. Peripheral resistance is the resistance to blood flow from the heart by the peripheral vasculature.

Which term refers to the difference between systolic pressure and diastolic pressure? A. Cardiac output B. Pulsus paradoxus C. Pulse pressure D. Peripheral resistance

B. Systolic pressure Systole occurs when blood is forced into the aorta during cardiac contraction. Diastolic pressure is the minimal pressure exerted against the arterial wall at all times. Hydrostatic pressure is the pressure of water at equilibrium, not under pressure. Peripheral resistance is the amount of resistance to blood flow applied by the vasculature.

Which term refers to the peak pressure that occurs when ventricular contraction forces blood under high pressure into the aorta? A. Diastolic pressure B. Systolic pressure C. Hydrostatic pressure D. Peripheral resistance

B. An electronic thermometer with an oral probe The electronic thermometer includes two separate probes, one for oral use (blue top probe) and one for rectal use (red top probe). The oral probe should be used for measuring axillary temperature; for infection control, the rectal probe should be used only for rectal temperature measurement. Temporal artery thermometers are not used to take axillary temperatures because the instrument is designed to measure a transcutaneous temperature using the temporal artery. Most municipalities have prohibited the sale or use of mercury-containing medical devices because of the potential hazards.

Which thermometer is the best type to use when measuring an axillary temperature? A. An electronic thermometer with a rectal probe B. An electronic thermometer with an oral probe C. A temporal artery thermometer D. A mercury thermometer

C. Patient with spinal precautions ordered Patients may not be able to get out of bed during a linen change because of postprocedure precautions, such as spinal precautions. In such cases, guidelines for making an occupied bed should be followed. Patients who have had hip surgery, those with a tracheostomy, and those with an arm fracture can usually get out of bed and are encouraged to ambulate during a linen change.

Which type of patient is most likely to remain in bed while the linens are changed?

B. The oral temperature method is not used on small children. One of the limitations of the oral temperature measurement is that it is not used on infants or small children. Some advantages, not limitations, of using the oral temperature method include: accurate surface temperature reading, accurate reflection of rapid changes in core temperature, and a reliable route for measuring the temperature in intubated patients.

What is one limitation of using the oral method of temperature measurement? A. The oral temperature method is not accurate for a surface temperature reading. B. The oral temperature method is not used on small children. C. The oral temperature method does not reflect rapid changes in core temperature. D. The oral temperature method cannot be used on intubated patients. Rationale: One of the limitations of the oral temperature measurement is that it is not used on infants or small children. Some advantages, not limitations, of using the oral temperature method include: accurate surface temperature reading, accurate reflection of rapid changes in core temperature, and a reliable route for measuring the temperature in intubated patients.

C. Rectal temperature is a reliable measurement when oral temperature cannot be obtained. The rectal site is considered reliable when the oral route is not accessible. The axilla site is advantageous for use on newborns and unconscious patients. The temporal membrane site is an easily accessible site and can be obtained without disturbing, waking, or repositioning the patient.

What is the advantage of using the rectal body temperature measurement? A. Rectal temperature can be used on newborns and unconscious patients. B. The rectum is an easily accessible site. C. Rectal temperature is a reliable measurement when oral temperature cannot be obtained. D. Temperature can be obtained without disturbing, waking, or repositioning the patient.

B. The patient and family can participate. When nurses give reports at the bedside, the patient and family members have the opportunity to participate. Together, with the patient and family, the nurses can see the patient to perform needed joint assessments, evaluate progress, and discuss the interventions best suited to the patient's needs. Although a bedside report enables the patient and family to participate in the process, it is not necessary to share all information related to the patient with the patient. A bedside report takes place at the patient's bedside, not in a conference room. Breeches in privacy are a potential negative consequence, not a benefit of bedside report. Nurses must use discretion in nonprivate situations.

What is the benefit of completing a bedside report during hand-off? A. The patient's roommate may overhear the patient's diagnosis. B. The patient and family can participate. C. The nurse gets to share all information with the patient. D. Patients are seen in the conference room.

D. The artery can be occluded and the nurse may end up counting his or her own pulse. Pulse assessment is more accurate when using moderate pressure. Too much pressure occludes the pulse, impairs the blood flow, and can result in the nurse counting his or her own pulse rate. Strength reflects the volume of blood ejected against the arterial wall with each heart contraction. Decreased elasticity and not the amount of pressure placed on an artery can make the vessel feel stiff and knotty. Decreased elasticity is a condition often found in older patients.

What is the result of applying too much pressure on the wrist when obtaining a radial pulse? A. The increased pressure increases the blood flow. B. The pressure reflects the volume of blood against the artery walls. C. The pressure makes the arteries feel stiff or knotty. D. The artery can be occluded and the nurse may end up counting his or her own pulse.

A. Place the linen in a linen bag immediately To reduce the risk of cross infection, the health care professional should take a linen bag to the patient's bedside, carefully remove the used linen, and place it in the linen bag immediately. The health care professional should not carry used linen across the room because doing so increases the risk of dissemination of microorganisms into the air or onto clothing. Linen should not be shaken or agitated before being placed in the linen bag. Placing soiled linen in the pillowcase increases handling and causes an additional risk of the dissemination of microorganisms.

What should the health care professional do after removing crumb-filled linen from an unoccupied bed? A. Place the linen in a linen bag immediately B. Shake the linen to remove food crumbs and then place it in a linen bag C. Carry the linen out of the room and discard it in the hall linen bag D. Place the linen in the pillowcase and place the pillowcase in the linen bag

A. Loosen the top linen at the foot of the bed Loosening the top linen at the foot of the bed makes removal easier. After the top linen has been loosened at the foot of the bed, the patient can be covered with a blanket. Next, the top linen is removed from the bed. Then the bottom linen is loosened to make removal easier.

What should the health care professional do first when removing the soiled linens from a bed? A. Loosen the top linen at the foot of the bed B. Remove the top linen from the bed C. Loosen the bottom linen D. Cover the patient with a blanket

B. Invert the pillowcase over one hand so that the inner back seam is visible When applying the pillowcase, the health care professional should first invert the pillowcase over one hand so that the inner back seam is visible. This facilitates guiding the pillowcase over the pillow. When the pillowcase is on, the seam should be inside it. The pillowcase should not be doubled, but should be changed more frequently if the patient is diaphoretic. The pillowcase should be guided over the pillow rather than the pillow being stuffed through the open end of the pillowcase.

What should the health care professional do when applying a clean pillowcase over the pillow? A. Make sure the pillowcase is on the pillow inside out with the seam showing B. Invert the pillowcase over one hand so that the inner back seam is visible C. Double the pillowcase for patients who are diaphoretic D. Stuff the pillow through the open end of the pillowcase

A. The skin of older adults is more fragile and susceptible to injury from cuff pressure. The skin of older adults is more fragile and susceptible to injury caused by cuff pressure, especially when measurements are frequent. Older adults lose upper arm mass, especially in the nondominant arm; thus, special attention to the selection of BP cuff size is needed. This loss of upper arm mass does not determine which arm is used for assessing BP. Older adults have a higher systolic pressure because of decreased vessel elasticity. Older adults often experience a fall in BP after eating, making it more difficult to compare the measurement to a baseline.

What should the nurse be aware of when assessing the BP of an older adult? A. The skin of older adults is more fragile and susceptible to injury from cuff pressure. B. Assessing BP soon after the patient has eaten is best. C. The systolic BP is usually lower than that of a middle-age patient. D. The BP should be assessed in the nondominant arm of an older adult.

D. Check for adequate capillary refill time. If capillary refill is prolonged, the nurse should select an alternative site. An IV site would be proximal to the finger sensor and would not interfere. The specific age of an adult patient is not relevant to the site choice. Rings can be worn during pulse oximetry assessment if they do not impede blood flow.

What should the nurse do before assessing an adult patient's oxygen saturation using a finger sensor? A. Check which arm has an IV site. B. Check the patient's age. C. Check the number of rings on each finger. D. Check for adequate capillary refill time.

C. At 7:00 AM Daily fluctuations in temperature are normal. Typically, temperatures are lowest in the early morning and highest in the early evening. The temperature falls gradually during the night. Exercise, surgery, and stress may all cause temperature elevations.

What time of day should the nurse expect the lowest temperature readings? A. At 7:00 PM B. During periods of stress C. At 7:00 AM D. In the immediate postoperative period

C. Higher than normal As the body increases its workload (in this case through exercise), it also increases its demand for oxygen, which causes the respiratory rate to increase accordingly. Therefore, the rate would become higher than normal when the patient is ambulating.

When a patient has been ambulating in the hall, what would be the expected response in the respiratory rate? A. Unchanged B. Lower than normal C. Higher than normal D. Normal

A. The method of temperature measurement The method of temperature measurement should always be listed when documenting the readings. Temperature trends are most accurate when the same method and location are used, as inaccurate measurements may result in improper treatment. Returning the temperature probe to the housing unit is part of the procedure. Verifying the correct patient and informing the patient about the use of antipyretics is part of patient and family education and is not data used to identify trends in temperature variations.

When documenting temperature readings, what is the most important factor to include? A. The method of temperature measurement B. The return of the temperature measurement device back into the housing unit C. Verifying the correct patient using two identifiers D. Informing the patient about the use of antipyretics as prescribed

C. Tucking the top sheet and blanket loosely under the mattress at the foot of the bed Tucking the top sheet and blanket loosely under the mattress at the foot of the bed decreases the chance of the feet rubbing the sheets and forming pressure ulcers on the patient's toes and heels. Tucking the linens tightly under the mattress at the foot of the bed can cause rubbing of the patient's feet on the sheets and result in pressure ulcers. Linens should be changed when soiled or wet but do not need to be changed more routinely than the organization's practice. Multiple drawsheets can create uncomfortable bumps in the bedding and areas of pressure.

The health care professional making an occupied bed should know that the following action helps avoid the development of a pressure ulcer.

A. Remove the thermometer immediately. If resistance is felt while inserting a rectal thermometer, the nurse should withdraw it immediately. Pressure or force should never be applied when resistance is encountered because mucosal trauma may result. Deep breaths may allow the patient to relax, but relaxation is not an indication that it is safe to advance the rectal thermometer.

When inserting a rectal thermometer, the nurse encounters resistance. Which action is most appropriate? A. Remove the thermometer immediately. B. Apply mild pressure to advance the thermometer. C. Instruct the patient to take deep breaths. D. Remove the thermometer and reinsert it more forcefully.

B. In the posterior sublingual pocket lateral to the center of the lower jaw Heat from superficial blood vessels in the sublingual pocket produces a temperature reading. With an electronic thermometer, temperatures in the right and left posterior sublingual pockets are significantly higher than in the area under the front of the tongue. The thermometer should not be placed between the tongue and the soft palate because an airway injury may result and the temperature reading will not be accurate. Placing a thermometer between the teeth or in the buccal pocket between the gums and the lips would not produce an accurate oral temperature reading.

When taking an oral temperature, the nurse should place the thermometer in which location? A. Between the tongue and the soft palate B. In the posterior sublingual pocket lateral to the center of the lower jaw C. Between the teeth D. In the buccal pocket between the gums and the lips

A. "Many things affect temperature, and temperature normally varies from person to person." No single temperature reading is normal for all people. Although the body usually functions best at 36°C to 38°C (96.8°F to 100.4°F), an acceptable temperature range for a patient depends on age, gender, physical activity, and the state of health.

The patient asks why his temperature is never 37°C (98.6°F). "Is there something wrong with me?" Which response is the most appropriate? A. "Many things affect temperature, and temperature normally varies from person to person." B. "I don't know what to tell you. Your temperature should be 37°C (98.6°F)." C. "Temperature is only 37°C (98.6°F) if you're not doing anything." D. "A temperature of 37°C (98.6°F) is normal for teenagers and people who are in shape. If you're out of shape, then your temperature could vary."

A. New pain during inspiration and expiration New pain experienced during both inspiration and expiration may indicate a new finding such as pneumonia or a broken rib. This would be a change in the patient's assessment and would necessitate a call to the practitioner. The patient's dyspnea is not new because it has been occurring with activity since admission. An SpO2 reading of 96% and a respiratory rate of 20 breaths per minute are within normal limits.

The patient complains of shortness of breath, which has been occurring since admission after activity such as walking. What new assessment should prompt the nurse to notify the practitioner? A. New pain during inspiration and expiration B. Shortness of breath after coming from the bathroom C. An SpO2 reading of 96% D. A respiratory rate of 20 breaths per minute

B. Correlating the oximeter pulse rate with the patient's radial pulse After placing the sensor and turning on the oximeter, the nurse should observe the pulse waveform or intensity display, listen for the audible beep (if available), and correlate the oximeter pulse rate with the patient's radial pulse. Alarm settings should be verified and adjusted after the patient's baseline reading has been established. Silencing the alarm would only occur after the alarm has been set and only if the alarm sounds. The nurse should monitor skin integrity periodically for breakdown, but this is not the next step.

The practitioner has ordered that a patient have continuous oxygen saturation monitoring. Which action is the nurse's next step after placing the sensor, turning on the oximeter, and observing the pulse waveform? A. Adjusting the alarm limits B. Correlating the oximeter pulse rate with the patient's radial pulse C. Silencing the oximeter's alarms D. Monitoring skin integrity under the sensor

B. Confidentiality Regardless of the form of the nursing report, confidentiality must be maintained; therefore, recording in a private area is essential. Staff convenience and the nurse's comfort may be improved by recording in a private area, but maintaining confidentiality is required. Noise level may be improved in a private area, but maintaining confidentiality comes first.

The progressive care unit uses a recorded system for nursing reports. In the past, nurses have designated positions in the hall where they could record and listen to reports. Now, the unit governance council has mandated that recording and listening must be done in the medication room, nurse lounge, or dictation room. What is the reason for this change? A. Noise level B. Confidentiality C. Staff convenience D. The nurse's comfort

B. Daily furosemide and metoprolol tartrate Medications that may cause physical or cognitive impairment and lead to falls include diuretics, antihypertensives, and psychotropics; furosemide is a diuretic, and metoprolol tartrate is an antihypertensive. A history of a broken hip, by itself, does not make the patient a current fall risk. Aspirin and potassium are not known to cause hypotensive syncope. Diabetes can cause many complications, but it has not been linked directly as a cause of falls.

The nurse has assessed an older adult female patient for fall risk. The patient, frail and slightly unsteady on her feet, has recently arrived from a nursing home. What puts the patient at the greatest risk of falling? A. A broken hip 5 years earlier B. Daily furosemide and metoprolol tartrate C. Daily aspirin and potassium D. Diabetes mellitus (type II)

A. BP is not routinely assessed in a 2-year-old child. BP is not a routine part of assessment in children younger than 3 years of age. Cuff size must be appropriate for the patient. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. BP measurement can frighten children, and anxiety can cause unreliable readings.

The nurse is about to obtain routine vital signs from a 2-year-old patient. Which statement regarding BP measurement in children is accurate? A. BP is not routinely assessed in a 2-year-old child. B. The size of the cuff does not affect BP readings in children. C. Korotkoff sounds are much easier to hear in children than in adults. D. Children usually enjoy BP assessments.

B. Infants and young children may have irregular breathing patterns. Infants and young children frequently have irregular breathing patterns, so the respiratory rate should be counted for 1 minute for accuracy. Irregular breathing patterns in young children are more often the result of anxiety. Fever would be a more likely indicator of a respiratory infection. Hyperpnea is indicated by excessively deep and shallow breathing.

The nurse is assessing the respiratory rate of a 3-year-old patient and notices an irregular pattern and rate. Which information should the nurse keep in mind? A. This pattern may indicate a respiratory infection. B. Infants and young children may have irregular breathing patterns. C. Irregular breathing patterns in young children are not usual findings. D. This finding indicates hyperpnea.

C. Check the patient's pulse at the end of the assessment. Anxiety can raise the pulse rate. If the patient's pulse rate is higher than expected, reassess it at the end of the physical assessment when the patient is more relaxed. Moderate pressure on the artery results in more accurate assessment results. If the pulse is irregular, the nurse should count the rate for a full 60 seconds. The count of one is the first beat palpated after timing begins.

The nurse is doing an initial assessment on a new patient. The patient is anxious and the patient's pulse, while regular, is higher than expected. What adjustment should the nurse make to obtain a more accurate pulse reading? A. Apply firm pressure to the pulse site. B. Count the rate for a full 60 seconds. C. Check the patient's pulse at the end of the assessment. D. Use the count of two for the first beat after the start of timing.

A. Determine if the patient uses a mercury-containing thermometer. The nurse should first determine the type of thermometer the patient uses. After determining if the patient uses a mercury-containing thermometer, the nurse should teach the patient and caregiver about mercury hazards. Education on the proper disposal of mercury-containing devices and recommending alternative devices is also completed after assessing the type of thermometer the patient has at home.

The nurse is educating the patient about obtaining body temperature when at home. What action should the nurse take first? A. Determine if the patient uses a mercury-containing thermometer. B. Educate the patient on the hazards of mercury. C. Assess for the presence of proper disposal containers for mercury-based thermometers. D. Educate the patient on alternative temperature measurement devices.

C. "Only the systolic BP can be detected via palpation." Only the systolic BP can be palpated. The cuff should be inflated above the point at which the pulse can no longer be palpated. In children, the right arm is preferred for BP measurements. The cuff should be deflated slowly, allowing the manometer needle to fall slowly; a decline that is too rapid would result in an inaccurate reading.

The nurse is explaining to a new graduate nurse how to palpate the patient's BP. Which statement would indicate the new nurse understands the information? A. "The left arm is preferred for BP measurements in children." B. "The cuff should not be inflated above the point at which the pulse can be palpated." C. "Only the systolic BP can be detected via palpation." D. "The cuff should be deflated rapidly."

B. Position of the patient's arm at the time of assessment The nurse should first check the position of the patient's forearm, confirming that it is at heart level with the palm facing up. Placement of the arm above the level of the heart causes falsely low readings. Leg crossing can falsely increase systolic and diastolic BP readings. Although sphygmomanometers can go out of calibration, if all other BP measurements obtained for other patients are reasonable, the problem is not likely to be the machine. If the patient's arm and legs are properly positioned, the nurse should verify the position of the stethoscope. Placing the stethoscope directly over the artery provides an accurate BP measurement; however, placement to the side of the artery may cause difficulty auscultating the BP and reduce accuracy.

The nurse is measuring a patient's BP in the upper extremity and finds that the patient's BP is lower than normal for the patient. The patient is asymptomatic. What should the nurse check first? A. Position of the patient's legs at the time of assessment B. Position of the patient's arm at the time of assessment C. Calibration of the sphygmomanometer D. Placement of the stethoscope over the artery

A. Obtain a temperature using a tympanic thermometer. A temporal thermometer is subject to inaccuracies when the patient's skin is wet. Using a tympanic thermometer is a comfortable and accurate alternative core assessment that is not affected by skin moisture and is less invasive than a rectal temperature. Because the patient continues to sweat, an alternate method is required for accuracy. Diaphoresis has not proven to be resolved after 30 minutes when the patient is at rest. If the patient had been exercising, a 20- to 30-minute rest period may have resolved the issue.

The nurse is obtaining the core temperature of a resting diaphoretic patient, using a temporal thermometer. The first reading is lower than expected, so the nurse dries the patient's forehead with a towel and repeats the measurement. The temperature is again lower than expected. Which action is the most appropriate? A. Obtain a temperature using a tympanic thermometer. B. Towel off the patient's forehead and obtain a third reading. C. Obtain a temperature using a rectal thermometer. D. Wait 30 minutes and use an alternate method to obtain the temperature.

D. Check to make sure the cuff has been completely deflated. The first action the nurse should take is to make sure the cuff is completely deflated. Keeping the cuff on too long or failing to completely deflate the cuff may cause an arterial occlusion, resulting in numbness and tingling of the affected extremity. The practitioner should be notified only if the numbness and tingling are not resolved by making sure the cuff is completely deflated. Inflating the cuff or obtaining another BP measurement may worsen the numbness and tingling and should be avoided.

The nurse is taking serial BP measurements. Several minutes after the nurse obtains a BP by palpation of the right arm, the patient starts to complain of numbness and tingling in the arm. Which action should the nurse take first? A. Notify the practitioner. B. Obtain another BP measurement. C. Inflate the cuff to 100 mg Hg and then slowly deflate it. D. Check to make sure the cuff has been completely deflated.

C. Helps the patient to a supine or sitting position. Assisting a patient to a supine or sitting position provides easy access to pulse sites. A relaxed position of the lower arm and extension of the wrist permits full exposure of the artery to palpation. Elevating the patient's arm or counting the pulse for 15 seconds and multiplying by 4 can lead to erroneous results. Applying significant pressure can obliterate the pulse.

The nurse knows that an assistant understands the proper technique for measuring the radial pulse when he or she takes which action? A. Counts the pulse for 15 seconds and multiplies by 4. B. Has the patient's arm elevated. C. Helps the patient to a supine or sitting position. D. Applies significant pressure to the pulse site.

D. Compare the temperature results with the patient's previous baseline and with the acceptable temperature range for the patient's age. Body temperature fluctuates in a narrow range; a comparison of readings can help identify trends and the presence of an abnormality. At the completion of the procedure, the nurse should remove gloves and perform hand hygiene. Verifying the correct patient using two identifiers, and assessing the patient for factors that affect temperature are steps completed before the procedure.

What action should the nurse take upon completion of body temperature measurement? A. Perform hand hygiene and don gloves. B. Verify the correct patient using two identifiers. C. Assess the patient for factors that normally affect temperature. D. Compare the temperature results with the patient's previous baseline and with the acceptable temperature range for the patient's age.

A. Dry mucous membranes, hypotension, and concentrated urine Symptoms of hyperthermia include decreased skin turgor, dry mucous membranes, decreased venous filling, and concentrated urine. Additional signs and symptoms of hyperthermia are hypotension and tachycardia. Heat stroke symptoms include hot, dry skin; tachycardia; hypotension; excessive thirst; muscle cramps; visual disturbances; and confusion or delirium. Pale skin, skin cool or cold to touch, bradycardia and arrhythmias, uncontrollable shivering, reduced level of consciousness, and shallow respirations are signs and symptoms of hypothermia.

What are some of the signs and symptoms of hyperthermia? A. Dry mucous membranes, hypotension, and concentrated urine B. Muscle cramps, visual disturbances, and confusion or delirium C. Hypertension and bradycardia D. Pale skin, reduced level of consciousness, and shallow respirations

D. The body temperature rises when the patient's heat-loss mechanisms do not keep up with heat production. An abnormal rise in body temperature is a failure of the patient's heat-loss mechanism's ability to keep pace with excess heat production. Physiologic changes associated with the aging process may result in a lower body temperature, not a higher body temperature. Administering antipyretic medications is a treatment to lower the body temperature, and does not cause a rise in body temperature. Temperature control mechanisms have failed when heat produced by the body is not equal to heat lost to the environment.

What causes an abnormal rise in body temperature? A. A rise in body temperature is related to physiologic changes as the body ages. B. Body temperature will rise during the administration of antipyretics. C. Body temperature rises when body temperature control mechanisms are equal to body heat lost to the environment. D. The body temperature rises when the patient's heat-loss mechanisms do not keep up with heat production.

A. Bounding and strong The amplitude of a pulse with a 4 rating is bounding and strong. The amplitude of a pulse with a score of 0 on a scale from 0-4 means the pulse is absent or nonpalpable. The amplitude of a pulse with a score of 1 means the pulse is diminished, difficult to palpate, thready, or weak. A score of 2 means the pulse is as expected, easy to palpate. A score of 3 indicates the pulse is full, increased.

What characteristics of the pulse would the nurse find if the pulse amplitude is given a 4 rating on a scale of 0 to 4? A. Bounding and strong B. Thready and weak C. Easy to palpate D. Absent

B. A site closest to a major artery Measuring core temperature is most accurate if using a site near a major artery. No one site correlates exactly with core temperature. Sites reflecting core temperature (rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature. Comfort for the patient is not a factor in determining the most accurate core temperature.

What factor in the selection of a body temperature site best correlates with accurate core temperature? A. Any chosen site can reflect accurate core temperature if obtained correctly B. A site closest to a major artery C. A site closest to the body's surface D. A site most comfortable for the patient

D. "Keep the thermometer securely under your arm until the reading is complete." The nurse should educate the patient about the importance of keeping the thermometer securely in the axilla until the reading is complete. Placing the patient's arm across his or her chest keeps the thermometer in the proper position against blood vessels in the axilla. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

What instruction should the nurse give the patient to obtain the most accurate axillary temperature reading? A. "Do not cross your arms over your chest." B. "It is important to wait for 30 minutes after exercising before taking your temperature." C. "It is important to wait for 1 hour after you eat or drink before taking your temperature." D. "Keep the thermometer securely under your arm until the reading is complete."

C. "Keep the thermometer securely under your tongue until the reading is complete." The nurse should educate the patient about the importance of keeping the thermometer securely under the tongue until the reading is complete. The patient should be instructed to hold the temperature probe with lips closed. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

What instruction should the nurse give the patient to obtain the most accurate oral temperature reading? A. "Hold the temperature probe with your tongue and keep your lips open." B. "It is important to wait for 30 minutes after exercising before taking your temperature." C. "Keep the thermometer securely under your tongue until the reading is complete." D. "It is important to wait for 1 hour after you eat or drink before taking your temperature."

D. The rectum A patient with a low platelet count (e.g., a patient with cancer) should not have anything inserted into the rectum because of the risk of bleeding. The mouth, the axilla, and the temporal region are all acceptable choices for temperature measurement for this patient.

A patient treated for cancer must have a body temperature measurement. Which site should the nurse avoid? A. The temporal region B. The mouth C. The axilla D. The rectum

A. "Lie on your side with your upper leg flexed." Assisting the patient to a comfortable side-lying position that provides easy access to the rectum helps ensure the patient's comfort and the accuracy of the temperature reading. The thermometer should be held in place until an audible signal indicates completion and the patient's temperature appears on the digital display. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

What instruction should the nurse give the patient to obtain the most accurate rectal temperature measurement? A. "Lie on your side with your upper leg flexed." B. "There is no need to hold the thermometer in place." C. "It is important to wait for 30 minutes after exercising before taking your temperature." D. "It is important to wait for 1 hour after you eat or drink before taking your temperature."

A. Allow a few centimeters to hang over the side mattress edge The flat sheet should be placed over the mattress with a few centimeters hanging over the side mattress edge to provide enough sheet material to tuck under the mattress. The sheet should be laid seam down. The health care professional should miter the top corner of the bottom sheet, making sure that the corner is taut. The health care professional should then grasp the remaining edge of the flat bottom sheet and tuck it tightly under the mattress while moving from the head to the foot of the bed.

When using a flat sheet as a bottom sheet, the health care professional should remember to complete which action? A. Allow a few centimeters to hang over the side mattress edge B. Make sure none of the flat sheet hangs over the mattress edge C. Place the lower hem of the sheet with its seam up, ensuring that it is even with the bottom edge of the mattress D. Keep the bottom corners even with the bottom edge of the mattress rather than tucking them

B. Family history of hypertension Family history cannot be altered to prevent hypertension. Smoking, hyperlipidemia, and obesity are risk factors that the patient can change to decrease the risk of developing hypertension.

The nurse is teaching a patient about modifiable and nonmodifiable risk factors for hypertension. Which risk factor cannot be modified by the patient? A. Smoking B. Family history of hypertension C. Hyperlipidemia D. Obesity

B. Large adult A cuff size that is appropriate for the patient should be proportionate to the circumference of the limb being assessed. Most adult patients require a large adult cuff for the lower extremity. Small, medium, and one size fits all are not common sizes for most adult patients.

The nurse is trying to decide on an appropriate-size cuff for a lower extremity BP measurement. The nurse should know that most adults require which cuff size? A. Medium adult B. Large adult C. Small adult D. One size fits all

D. Smoking, anemia, and pneumonia Smoking, anemia, and pneumonia are major risk factors for alterations in respiration. Osteoporosis would not affect respiration unless the chest ribs were broken. Age is not necessarily a risk factor for respiratory alterations unless combined with other illness or disease.

What are major risk factors for a patient's alterations in respiration? A. Anemia, pneumonia, and osteoporosis B. Pneumonia, osteoporosis, and age C. Osteoporosis, age, and smoking D. Smoking, anemia, and pneumonia

D. The method of temperature measurement The method of temperature measurement should always be listed when documenting the intervention. Temperature trends are most accurate when the same method and location are used, as inaccurate measurements may result in improper treatment. Returning the temperature probe to the housing unit is part of the procedure. Verifying the correct patient and informing the patient about the use of antipyretics is part of patient and family education and not related to identifying trends in temperature variations.

Which action is most important when documenting temperature readings? A. The return of the temperature measurement device back into the housing unit B. Verifying the correct patient using two identifiers C. Informing the patient about the use of antipyretics as prescribed D. The method of temperature measurement

D. Can be used on newborns and unconscious patients The axillary site can be used to obtain body temperature on unresponsive patients and babies. Easy access to the site and very rapid measurement are two advantages of the temporal artery location. Being comfortable for the patient is an advantage of using the oral method.

What is one advantage of using the axillary method of obtaining body temperature? A. Easy to access without a position change B. Rapid measurement can be obtained C. Comfortable for the patient D. Can be used on newborns and unconscious patients

B. Prioritize information on the basis of the patient's needs and problems. When preparing a nursing report, the reporting nurse should prioritize information based on the patient's needs and problems and report relevant information to the accepting nurse. It is important that the nursing report be concise, so the reporting nurse cannot review the patient's entire health record. Relevant information may include information from a time other than the past 24 hours and the last shift.

When preparing a nursing report, which of the following steps should the reporting nurse take? A. Identify only changes that have occurred during the shift. B. Prioritize information on the basis of the patient's needs and problems. C. Review the complete health record. D. Identify only events that have occurred in the past 24 hours.

D. Skin lesions and excessive perspiration Excessive perspiration may cause an inaccurate reading. Skin lesions may cause patient discomfort. Axillary hair, cyanosis, pallor, and skin dryness are not contraindications for measuring axillary temperature.

When preparing to take an axillary temperature, the nurse should check the patient's axilla for which condition? A. Excessive dryness B. Excessive axillary hair C. Cyanosis or pallor D. Skin lesions and excessive perspiration

D. Before assessment of other parameters Assessing respirations first allows a more accurate assessment of rate and rhythm before the child becomes anxious because of fear of strangers or other assessment procedures. Temperature and pulse assessments may evoke anxiety in the child, thereby affecting the respiratory rate.

When should a child's respiratory rate be assessed? A. After assessment of the apical pulse B. During temperature assessment if a tympanic thermometer is used C. During assessment of the apical pulse D. Before assessment of other parameters

B. At 7:00 AM Daily fluctuations in temperature are normal. Typically, temperatures are lowest in the early morning and highest in the early evening. The temperature falls gradually during the night. Exercise, surgery, and stress may all cause temperature elevations.

When should the nurse expect the lowest temperature readings? A. At 7:00 PM B. At 7:00 AM C. During periods of stress D. During the postoperative period

A. Place the patient's arm or the examiner's hand gently over the patient's upper abdomen. One method of assessing a patient's respiratory rate is to place the patient's arm in a relaxed position across the abdomen or lower chest or place the examiner's hand directly over the patient's upper abdomen and count the number of respirations as the abdomen rises and falls. Placing the bed flat or removing supplemental oxygen may create respiratory distress. Assessment of respirations should be inconspicuous, so the nurse should avoid explaining to the patient.

Which is an appropriate method of assessing a patient's respirations? A. Place the patient's arm or the examiner's hand gently over the patient's upper abdomen. B. Place the bed flat. C. Remove supplemental oxygen sources. D. Explain to the patient that respirations are being assessed.

B. Temporal Core temporal temperature measurements may be obtained in a preterm neonate without unbundling. Axillary temperature measurements may be used for screening purposes but cannot be relied on to detect fevers in an infant and young child. Sites reflecting core temperature (temporal, rectum, tympanic membrane, esophagus, pulmonary artery, urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, axilla).

When taking core temperature measurements in preterm neonates, the nurse should use which site? A. Axillary B. Temporal C. Skin D. Oral

B. Right hand Accurate temperature measurement with a tympanic thermometer requires the correct probe angle. When holding the handheld unit with the right hand, the nurse should obtain the temperature from the patient's right ear; nurses who are left handed should obtain the temperature from the patient's left ear. Both hands are not needed to hold the thermometer at the correct angle.

When using the handheld tympanic thermometer in the patient's right ear, the nurse should use which hand? A. Left hand B. Right hand C. Either hand D. Both hands

B. Observe the degree of chest wall movement while counting the respiration rate. When assessing the depth of a patient's respirations, the nurse can observe the degree of chest wall movement while counting the respiratory rate. Other methods include palpating chest wall excursion on the anterior chest and auscultating the posterior thorax. Asking the patient to take deep breaths and hold it or to take slow deep breaths does not assess the depth of the patient's normal respirations.

Which method is the best way to assess the depth of a patient's respirations? A. Ask the patient to take a deep breath and hold it. B. Observe the degree of chest wall movement while counting the respiration rate. C. Ask the patient to take slow deep breaths. D. Auscultate the anterior chest.

A. First BP is recorded with the systolic reading (first Korotkoff sound) before the diastolic (beginning of the fifth Korotkoff sound).

Which of the following Korotkoff sounds indicates systolic BP? A. First B. Second C. Third D. Fourth

C. "Let me help you to a comfortable position and then turn your head away from me." Appropriate positioning facilitates the exposure of the auditory canal for accurate temperature measurement. The less acute the angle of approach, the better the probe seal. Heat trapped in the ear facing down will cause an artificially high temperature reading; if the patient has been lying on his or her side, use the upper ear. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring a body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

What instructions does the nurse give the patient to obtain the most accurate tympanic temperature reading? A. "The ear on the side you have been lying is the appropriate ear in which to obtain your temperature." B. "It is important to wait for 30 minutes after exercising before taking your temperature." C. "Let me help you to a comfortable position and then turn your head away from me." D. "It is important to wait for 1 hour after you eat or drink before taking your temperature."

A. Use a disposable sensor. A clip-on sensor may not fit properly on the finger of an obese patient, so a disposable sensor should be used. The sensor should not be placed on an edematous finger because it may alter skin integrity. The sensor is not designed to be placed on the thumb. The sensor should not be placed on a finger of an arm with a blood pressure cuff because cuff inflation may cause an inaccurate reading.

What is most appropriate intervention when monitoring the oxygen saturation of an obese patient using a pulse oximeter? A. Use a disposable sensor. B. Place the sensor on the most edematous finger. C. Affix the sensor to the thumb of the dominant hand. D. Place the sensor on a finger of the arm with the blood pressure cuff.

D. Stay until after the accepting nurse listens to the report. A recorded report is acceptable as long as the reporting nurse is available for questions after the accepting nurse listens to the report. Although it may be acceptable by organization practice for the reporting nurse to leave before providing an opportunity for questions, it is safer if the exchange can occur when the reporting nurse is still present on the unit to address concerns that were not addressed during the report. Even if the accepting nurse arrives early, it is safer for the reporting nurse to remain until the accepting nurse has had the opportunity to listen to the recorded report and ask questions. Accepting nurses may be reluctant to call a colleague at home.

Which of the following strategies is the safest when providing a recorded nursing report? A. Ask the charge nurse to cover the patient's care so that the reporting nurse can leave. B. Call the accepting nurse to see if he or she can come in early. C. Leave after recording the report, with instructions for the accepting nurse to call with questions. D. Stay until after the accepting nurse listens to the report.

C. Prone The prone position provides the best access to the popliteal artery and is therefore preferred. However, if the patient is unable to assume the prone position, the supine position with the knee slightly flexed is also acceptable. Neither the side-lying nor the Sims positions are acceptable for measuring BP in the lower extremity.

Which patient position is preferred during BP assessment of the lower extremity? A. Side-lying B. Supine C. Prone D. Sims

D. Temperatures considered within the normal range often reflect a fever in an older adult. The normal physiologic changes associated with the aging process may result in a lower body temperature, which coupled with less temperature variability may result in a blunted fever response. Therefore, temperatures considered within the normal range often reflect a fever in an older adult. A normal temperature for an older adult is at the lower end of the acceptable temperature ranges for adults. Older adults are sensitive to environmental temperature changes because their thermoregulatory systems are not as efficient.

4. Which statement is true regarding body temperature for an older adult patient? A. Older adults are normally at the upper end of the normal temperature range for adults. B. The normal physiologic changes associated with the aging process may result in a higher body temperature for an older adult. C. Older adults are not sensitive to environmental temperature changes because their thermoregulatory systems are efficient. D. Temperatures considered within the normal range often reflect a fever in an older adult.

D. Thumb side of the forearm at the wrist The radial artery is located on the thumb side of the distal forearm at the wrist. The ulnar pulse is best palpated on the ulnar side of the forearm at the wrist. The popliteal artery is located behind the knee in the popliteal fossa. The brachial artery is located in the groove between the biceps and triceps muscles at the antecubital fossa.

7. Where is the radial artery located in the body? A. Ulnar side of forearm at wrist B. Behind the knee in the popliteal fossa C. In the groove between the biceps and triceps muscles at the antecubital fossa D. Thumb side of the forearm at the wrist

B. 38°C (100.4°F) For a child younger than 3 months of age, a rectal temperature higher than 38°C (100.4°F) constitutes fever. For an infant between 3 and 24 months of age, a temperature of 38.3°C (101°F) or higher likely constitutes fever. For a child older than 2 years of age, fever more commonly is defined as a rectal temperature higher than 38°C (100.4°F).

A 2-month-old infant has a fever when the rectal temperature is higher than which temperature point? A. 37.5°C (99.5°F) B. 38°C (100.4°F) C. 38.3°C (101°F) D. 38.5°C (101.3°F)

B. An irregular heart rhythm, which is not uncommon in young children Children commonly have a sinus arrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration. The irregular rhythm may not be a cause for excessive concern, but it should be evaluated to ensure that it does not present a problem for the child. Breath holding in a child affects pulse rate. Crying and breath holding do not cause atrial fibrillation.

A nurse is taking the radial pulse of a 26-month-old child who has been crying and holding her breath. The nurse knows that the child's actions can cause which problem? A. A serious arrhythmia that needs immediate attention B. An irregular heart rhythm, which is not uncommon in young children C. A totally normal rhythm that is no cause for alarm D. Atrial fibrillation that puts the child at risk of a stroke

A. The patient receives continuity of care. An effective nursing report exchange ensures that the accepting nurse understands what is happening with the patient and how best to meet the patient's identified needs. This is a key factor leading to continuity of care. Although new practitioner orders may be detailed during the nursing report, the primary purpose is the transfer of information to ensure continuity of care. New trends in care are usually discussed in education programs, not nursing reports. Stabilizing the patient's risk status is part of nursing intervention, not a nursing report.

A nursing report is an important component of care. During the report, what is the primary purpose of an effective exchange of information? A. The patient receives continuity of care. B. The accepting nurse receives notification of new practitioner orders. C. New trends in care are identified. D. The patient's risk status is stabilized.

A. Kussmaul respiration ussmaul respirations—abnormally deep, regular, and increased in rate—are common in diabetic ketoacidosis. Cheyne-Stokes respiration is characterized by a respiratory rate and depth that are irregular with alternating periods of apnea and hyperventilation. Hyperpnea refers to excessively deep or labored breathing. Biot respirations are abnormally shallow for two or three breaths, followed by an irregular period of apnea.

A patient admitted with diabetic ketoacidosis has cracked lips and dry mucous membranes. Respirations are deep, regular, and rapid. What is this type of respiratory pattern called? A. Kussmaul respiration B. Hyperpnea C. Biot respiration D. Cheyne-Stokes respiration

C. Earlobe sensor Because of its central location, the earlobe is likely the most appropriate site for the patient with Parkinson's disease. The tremors in a patient with advanced Parkinson's disease are likely to be most severe in the extremities, interfering with the pulse oximeter's ability to detect a reading accurately, so a toe or finger sensor would be inappropriate. Disposable sensor pads are more expensive, decrease the ease of assessing skin integrity, can result in skin irritation in sensitive patients, and generally are used only with infants.

A patient has been admitted with a diagnosis of advanced Parkinson's disease. The nurse needs to assess the patient's oxygen saturation. Which sensor would be the most appropriate to use on this patient? A. Toe sensor B. Finger sensor C. Earlobe sensor D. Disposable sensor pad

C. Rectally Sites reflecting core temperature (rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, and axilla). In this case, the oral route is not appropriate because oral inflammation may alter temperature readings. The body rash renders the axillary method inaccurate because skin lesions may alter local temperature. Pulmonary artery catheters provide the most accurate way to obtain a core temperature, but the necessary invasive central-line insertion is not warranted in this case.

A patient has had a reaction to antibiotic therapy after oral surgery and has a rash over the entire body. How should the nurse assess the patient's temperature? A. Via the right axilla B. Orally C. Rectally D. Via a pulmonary artery catheter

C. Check the carotid pulse. The nurse checks the carotid pulse to assess core circulation. Carotid pulse assessment is often used during physiologic shock or cardiac arrest when other sites, such as the ulnar or temporal, are not palpable. The practitioner should be called immediately after airway, breathing, and circulation have been assessed.

A patient is difficult to arouse, and the nurse is unable to obtain a radial pulse. After observing deep and regular breathing, the nurse should take which action? A. Call the practitioner. B. Check the ulnar pulse. C. Check the carotid pulse. D. Check the temporal pulse.

A. Cover the pulse oximetry sensor. Heat and light sources can affect pulse oximetry sensors, so the sensor should be covered before use in a radiant warmer. The baby should not be removed from the warmer because neonates lose heat quickly. An earlobe sensor should not be used on a neonate. Skin protection lotion may be used on neonates before sensor placement to prevent stripping, tears, or blisters.

Which precaution should the nurse take when measuring pulse oximetry on a neonate in a radiant warmer? A. Cover the pulse oximetry sensor. B. Take the neonate out of the warmer for pulse oximetry measurement. C. Use an earlobe sensor. D. Remove any lotion from the baby's skin before placing the sensor.

C. Assess the pulse in the left arm. The nurse should compare radial pulses bilaterally. A marked inequality may indicate that arterial flow is compromised to one extremity, and action should be taken. Assessing the carotid pulse is part of a comprehensive assessment, but not the next step. Having the patient lie down could change the pulse, making a comparative assessment more difficult, and it is not necessary unless other conditions make this an important assessment for the patient. There is no need to contact the practitioner unless the findings are abnormal.

A patient is sitting up in bed. The nurse has obtained a radial pulse in the patient's right arm. Which intervention should the nurse perform next? A. Contact the practitioner immediately. B. Assess the carotid pulse for a pulse deficit. C. Assess the pulse in the left arm. D. Have the patient lie down.

D. A forehead sensor For patients with decreased peripheral perfusion, a forehead sensor is appropriate. A vascular, pulsatile area is needed to detect the change in the transmitted light when taking measurements with a digit sensor. A sensor applied to the finger would give inaccurate readings because of the poor circulation caused by the vasoconstriction.

A patient is taking a medication that causes peripheral vasoconstriction, resulting in poor circulation to the hands and feet. The nurse can best assess the patient's oxygen saturation using which sensor? A. A finger sensor on the arm opposite the automatic blood pressure cuff B. A disposable finger sensor C. A reusable finger sensor D. A forehead sensor

B. Have the patient sit and rest for several minutes. If the patient has been active, the nurse should wait several minutes before assessing the pulse; to obtain an accurate assessment, the nurse should encourage the patient to relax as much as possible. The patient's temperature and respiratory rate could be falsely elevated after exercise. A patient should not receive medication for the sole purpose of obtaining discharge vital signs.

A patient scheduled for discharge in the morning is eager to go home and has been pacing around the medical-surgical unit for the last hour. Which action should the nurse take before assessing patient's pulse? A. Assess the patient's temperature and respirations. B. Have the patient sit and rest for several minutes. C. Give the patient pain medication. D. Give the patient antianxiety medication.

C. Cheyne-Stokes respiration Cheyne-Stokes respiration is characterized by a respiratory rate and depth that are irregular with alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to an abnormal rate and depth. The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes. Hyperpnea refers to excessively deep or labored breathing. Kussmaul respirations are abnormally deep and regular and are common in diabetic ketoacidosis. Biot respirations are abnormally shallow for two or three breaths, followed by an irregular period of apnea.

A patient was involved in a motor vehicle crash that resulted in major head trauma 2 days ago. The nurse has observed that the patient's breathing pattern has been irregular with cycles of shallow breaths that gradually increase in rate and depth, then slow to periods of apnea, only to start over again. What is this type of breathing called? A. Hyperpnea B. Kussmaul respiration C. Cheyne-Stokes respiration D. Biot respiration

A. Place a drawsheet over the mattress Placing a drawsheet on the mattress provides the health care professional with a means of repositioning the patient in bed. Fitted sheets are convenient but do not assist with repositioning the patient. Extra pillows do not assist with repositioning the patient. The bed should always be kept in a low position for patient safety.

A patient who has just had abdominal surgery is in the bathroom, and the health care professional is making the unoccupied bed. How should the health care professional prepare the bed so the patient can be repositioned in bed? A. Place a drawsheet over the mattress B. Use fitted sheets on the bed C. Place extra pillows on the bed D. Keep the bed in a high position

C. Obtaining a second measurement soon after the initial one Obtaining a repeat temperature after an elevated reading confirms the initial finding. Reassessment in 4 hours may result in delayed diagnosis and treatment. If the patient has a fever, antipyretics should be administered, and the temperature should be remeasured until it stabilizes. Body temperature normally fluctuates within a narrow range. Reporting the change may result in treatment for a normal process.

A patient's oral temperature is 38°C (100.4°F). The baseline temperature on admission was 36°C (96.8°F). Which intervention is the most appropriate for this patient? A. Obtaining a second measurement in 4 hours B. Obtaining a second measurement within 30 minutes C. Obtaining a second measurement soon after the initial one D. Reporting the change to the practitioner

A. Obtain a new sensor. If the finger sensor for pulse oximetry is not functioning properly, the nurse should obtain a new sensor. A finger sensor should not be used on the earlobe or the nose; each sensor is designated for a specific part of the body. Documenting that a pulse oximetry reading is unobtainable is not acceptable; the practitioner's order for pulse oximetry monitoring must be followed.

A reusable pulse oximetry sensor on a patient's finger does not pick up a consistent waveform or a pulse. What should the nurse do? A. Obtain a new sensor. B. Place the sensor on the earlobe. C. Attach the sensor to the bridge of the nose. D. Document that the pulse oximetry reading is unobtainable.

B. The patient had recent prostate surgery. Contraindications for use of the rectal site for body temperature measurement include internal or external hemorrhoids, rectal bleeding or rectal surgery, bleeding tendencies, recent prostate surgery, fecal impaction, diarrhea, or the presence of a colostomy. The rectal site should also not be used on a confused or combative patient. Being in a side-lying position is the preferred position for obtaining a rectal temperature. Sites reflecting core temperature, such as the rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder, are not contraindications for use of that site. Core temperature readings are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, and axilla)

Which sitaution is a contraindication for obtaining a rectal temperature? A. The patient is in a side-lying position. B. The patient had recent prostate surgery. C. The rectal site is not an accurate reflection of the body's core temperature. D. The rectal site indicates only surface temperature.

C. Tympanic membrane Sites reflecting core temperature (rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, and axilla). Surface temperatures vary because of external factors, such as ambient temperature.

Which site is the most reliable for measuring an adult core body temperature? A. Axilla B. Oral cavity C. Tympanic membrane D. Skin

B. The first temperature reading provides a baseline for comparison with future temperature measurements. Normal body temperatures vary among individuals. A baseline measurement for each patient is needed to assess the patient for clinical changes. A second measurement confirms the initial findings of any abnormal temperature. Precise monitoring is achieved when the same method is used. No single temperature is normal for every person. In clinical practice, personnel providing care to a patient should learn an individual patient's temperature range.

Which statement about taking a body temperature measurement for the first time is true? A. One measurement is adequate to determine any changes in the patient's condition. B. The first temperature reading provides a baseline for comparison with future temperature measurements. C. Multiple sites may be used for accurate temperature measurements. D. Every patient has the same range of temperature readings.

A. Count the rate for a full 60 seconds. If the pulse is irregular, the nurse should count the rate for a full 60 seconds to help ensure an accurate estimate of bpm. If the pulse is regular, the nurse may count the rate for 30 seconds and multiply by 2; however, the pulse was irregular in this patient. An accurate radial pulse cannot be obtained in only 15 seconds, and generally counting the rate for 2 minutes is unnecessary.

Which statement describes the correct method of assessing a radial pulse in a patient who has an irregular pulse? A. Count the rate for a full 60 seconds. B. Count the rate for 15 seconds and multiply by four. C. Count the rate for 30 seconds and multiply by two. D. Count the rate for 2 minutes.

A. "If I am short of breath, I will check my pulse oximetry reading." The purpose of pulse oximetry is to monitor the oxygen saturation of the blood. Therefore, if a patient is short of breath, the procedure should be implemented. Smoking decreases the oxygen saturation of the blood. Pulse oximetry is a painless procedure, and pain medication is not needed. Restlessness may be caused by a low oxygen saturation, but it is not caused by the monitoring of oxygen saturation.

Which statement indicates that the patient understands the nurse's teaching on pulse oximetry? A. "If I am short of breath, I will check my pulse oximetry reading." B. "Smoking will not affect my pulse oximetry reading." C. "I should take my pain medication before checking my pulse oximetry reading." D. "This procedure may cause me to be a little restless."

B. Rectal body temperature measurements are 0.5°C (0.9°F) higher than oral body temperature measurements. Research findings from numerous studies are contradictory; however, it is generally accepted that rectal temperatures are usually 0.5°C (0.9°F) higher than oral temperatures. Axillary and tympanic temperatures are usually 0.5°C (0.9°F) lower than oral temperatures.

Which statement is generally accepted regarding rectal body temperature measurements? A. Rectal body temperature measurements are 0.5°C (0.9°F) higher than axillary body temperature measurements. B. Rectal body temperature measurements are 0.5°C (0.9°F) higher than oral body temperature measurements. C. Rectal body temperature measurements are 0.5°C (0.9°F) lower than oral body temperature measurements. D. Rectal body temperature measurements are the same as oral body temperature measurements